Camp Overlook Registration Form

- Please print this form and fax or mail it to us. -
- Have a group of 5 or more? To request a Group Discount Form contact the camp office (540)269-2267 -
Fax# (540)269-2267 same as the office #
Participant's      
Last Name: ____________________ First Name : ____________________
Nick Name: ____________________ Gender : ____________________
Birthday: ____________________ Grade Completed ____________________
Height ____________________ Weight ____________________

Address		      
Street: ____________________ City: ____________________
State: ____________________ Zip: ____________________
Parent or Guardian: ____________________ Home Phone: ____________________
Family e-mail: ____________________ Emergency Phone: ____________________
Church Participant Attends: ____________________ District (Circle one): Winchester, Harrisonburg, Staunton
First Choice Event: ____________________ Date: ____________________
Second Choice Event: ____________________ Date: ____________________
Participants first time away from home for a week ? ____________________ Has participant attended Overlook before? ____________________
If participant wishes to be grouped with ONE friend of the SAME age and grade we will try to place them together. Friends name: ____________________
Important or helpful infomation(e.g. allergies, fears, restrictions, etc.) ____________________________________________
In signing this application, I hereby certify that the registrant is in good health and may participate in ordinary camping activities as noted above. I authorize the officials at camp to act in any emergency. In case of surgical emergency, I give permission to the physician selected by the camp to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for the participant. Should itbecome necessary for the participant to return home because of illness or other reason, I will abide by the camp's decision and provide transportation. I also give the camp permission to use pictures including the participant in camp publicity.
Parent/Guardian Signature: ____________________ Date: ____________________

For office use only:
Housing: ____________________ Counselor: ____________________
Rec'd w/Reg: _______ Discount: _______ Scholar.: _______ Bal. Due: _______ Rec'd at Camp: _______

Complete for Visa / Mastercard Payment.
Cardholder's Name: ____________________ Amount $ ____________________
Address: ____________________ Credit Card #: ____________________
City, State: ____________________ Exp. Date: ____________________
Zip: ____________________ Payment is for: Deposit / Balance
Phone: ____________________ Camper's Name: ____________________


Address:
3014 Camp Overlook Lane, Keezletown, Virginia, 22832

**Registration cannot be accepted without $100.00 deposit ($50 refundable with 7 days notice prior to event)

Registrations are accepted on a first-come first-served basis.
A health form and suggested packing list will be sent with confirmation letter.
Confirmation of registration will be mailed after May 1, or
receive confirmation by e-mail directly!