2026 Special Needs VBS Application

2026 Special Needs VBS Application

The Heights Baptist Church
Thank you for your interest in The Heights Special Needs VBS. Please complete the following application to be considered for placement in VBS.

NOTE: Completion of this application does NOT guarantee a spot in Special Needs VBS. Once you have completed your application, The Heights staff will be in touch regarding your child's placement.

APPLICATION STEPS

To ensure a successful application process, please make sure you have completed all sections. Once your application is received, it must be processed and approved before your camper is accepted:

Application Steps
Review VBS Dates
Child's Information
Primary and Emergency Contacts
Current Level of Support Needs
Activity Eligibility
Waiver Acknowledgements and Release Forms

DETAILS

The Heights Special Needs VBS is an inclusive day camp experience designed for elementary age children with intellectual and physical disabilities that would not be able to participate in a traditional VBS or WinShape due to their high support needs. Elementary-age siblings are invited to participate as well.

The volunteers serving at VBS are not trained to support campers with aggressive behavior. If your child exhibits these behaviors, caregivers will need to provide a behavior therapist that can pass a background check to support the camper.

LOCATION: The Heights Baptist Church 17201 Route 1, South Chesterfield, VA 23834

Time: 9:00-12:00p
DATES: July 20-24, 2026
Child's Name*

First NameLast Name
Youth SmallYouth MediumYouth LargeAdult XSAdult MAdult LAdult XL
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Age*
MaleFemale
Primary Contact Name*

First NameLast Name
Primary Contact Cell Number*
Please enter a valid phone number.Format: (000) 000-0000.
Primary Contact Email*
example@example.com
Primary Contact Relationship to Camper*
Secondary Contact Name*

First NameLast Name
Secondary Contact Cell Number*
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Contact Relationship to Camper*
example@example.com
Emergency Contact information is used when primary and secondary contacts are not responding)
Emergency Contact Name*

First NameLast Name
Emergency Contact Relationship to Participant*
Please enter a valid phone number.Format: (000) 000-0000.
REFERENCE INFORMATION
Name of Teacher/Therapist/Clinician

First NameLast Name
Agency
Reference Phone
Please enter a valid phone number.Format: (000) 000-0000.
Reference Email
example@example.com
Mild AutismModerate AutismSevere/Profound AutismDown SyndromeCerebral PalsyEpilepsySpina BifidaHead Injury/Traumatic Brain InjuryFragile X SyndromePICASpinal Cord InjuryMuscular DystrophyVisual ImpairmentHearing ImpairmentSpeech-Language ImpairmentFeeding DisorderAsthmaAttention Deficit DisorderOther conditions or concerns (including psychiatric)
Other conditions (please specify)
YesNo
Please list any allergies, to include: medication, food, environmental, or animal allergies
If your camper has an allergy, please describe the allergic reaction.
Does the camper take emergency medication for allergic symptoms? If yes, please describe.
Does Not ApplyPsychomotorTonic-ClonicNocturnalNon-convulsive (Petit Mal)Other
Walks/runs independentlyWalking ability affected but walks independentlyWalks with assistance of hand holdingUses assistive device (walker, crutches, cane)
If using an assistive device, please identify
Speaks clearlyUnderstands complete sentences/directionsUses sign languageUnderstands sign languageUses word cardsSpeaks but is difficult to understandUses pictures (PECS)Uses communication board or AAC deviceUses gestures, pointsIs not able to follow directions or understand spoken language
Normal visionMild/moderate visions limitationsSevere/total loss of visionWears corrective lenses/glasses
Normal hearingMild/moderate hearing lossSevere/total loss of hearingWears hearing aids
Uses toilet independentlyNeeds to be reminded for toiletingNeeds assistance with toiletingHas a bowel/bladder schedule
Please describe assistance/schedule needs for toileting
Independent with dressingNeeds assistance
Please describe assistance needed with dressing
BEHAVIOR SUPPORTS

Please indicate how often, if ever, the following behavior occurs and how staff should respond.
NeverSometimesOften
NeverSometimesOften
NeverSometimesOften
NeverSometimesOften
NeverSometimesOften
NeverSometimesOften
NeverSometimesOften
NeverSometimesOften
NeverSometimesOften
NeverSomestimesOften
Please provide accurate and detailed information so we can best support your child in a way that is consistent and familiar.
Please describe in detail any challenging behaviors and what we should know about*
What activities, sights, sounds, or events trigger challenging behaviors?*
What are the key actions, words, or phrases to stop and redirect behavior?*
What are effective rewards to mitigate challenging behaviors?*
YesNo
Sibling(s)
RELEASE FROM LIABILITY

In consideration of my and/or my child(ren)'s participation in the activities sponsored by The Heights Baptist Church (also known as The Heights), I hereby agree to assume all risks upon myself and/or my child(ren) while participating in The Heights related activities. I hereby waive, release, and discharge any and all claims for damage for death, personal injury or property damage which I and/or my child(ren) may have, or which may hereafter accrue to myself and/or my child(ren), as a result of my and/or my child(ren)'s participation in The Heights activities. I agree to save and hold harmless from liability The Heights and/or any or its agents, volunteers, or employees by reason of accident, death, injury, or damages to person or property which I and/or my child(ren) may suffer while participating in The Heights activities. This release is intended to discharge in advance The Heights and/or any of its agents, volunteers, or employees by reason of any accidents, death, injury, or damages to persons or property which I and/or my child(ren) may suffer from and against any and all liability arising out of or connected in any way with my and/or my child(ren)'s participation in The Heights activities, even though that liability may arise out of negligence of carelessness on the part of the persons or entities mentioned above. It is further understood and agreed that this waiver, release and assumption of risk is to be binding on the heirs and assigns of myself and/or my child(ren). I agree to assume all responsibility for any property damage or injury to any person caused by myself and/or my child(ren) while participating in The Heights activities.

This authorization is continuous and may only be withdrawn by my specific rescinding, in writing, or this authorization.
I have read and agree with the terms and conditions aboveI do not agree with the terms and conditions above
PHOTO/VIDEO RELEASE

I understand that during Special Needs VBS photography/video and/or the photograph/video or myself and/or my child(ren) may be taken by church producers, sponsors, organizers, and/or assigns. I agree that my photograph and/or the photograph of my child(ren), including video photography, filmphotography, or other reproduction of my likeness or the likeness of my child may be used without charge by The Heights, its producers, sponsors, organizers, and/or its assigns for educational, promotional, and/or other necessary purposes. This material may also appear on The Heights website or other electronic formats. I also understand that once an image is posted electronically, the image can be viewed by any computer user whether or not a member of The Heights.

This authorization is continuous and may only be whithdrawn by my specific recinding, in writing, of this authorization.
I have read and agree with the terms and conditions aboveI do not agree with the terms and conditions above
The waivers and releases herein are intended to cover me and/or my child(ren). Please enter your name below as an e-signature.*
Should be Empty: