CAMP ACCOVAC

CAMP ACCOVAC

This application is for Summer Camp 2026! Online registration will close on May 31, 2026. All registration forms after that will have to be done on paper and brought with you to registration!
Camp ACCOVAC

Junior Week 1: June 14-20 (ages 7-12)

Junior Week 2: June 21-27 (ages 7-12)

Sports, Music, Drama Teen Camp: June 28 - July 4 (ages 12-17)

Work & Wilderness Teen Camp: July 5 - 11 (ages 12-17)

33021 Mountain Valley Rd.

Millboro, VA 24460

Camp Phone Number: 540-997-5964

campaccovac@yahoo.com

Director: Brandon Clemons

New Policy: Visitors will only be allowed during chapel services. Visitation times will be posted at the end of the driveway during drop off and throughout the week. Parents will be reminded of visitors policy at check-in.

Cabin Assignments: We will make cabin assignments as applications are received. You may select bunk mates but no one is gauranteed the bunk mates they select. Cabins are divided by age and gender.

Please mail a $25 registration fee per camper, per week to the address above to hold your camper's spot. Registration fee will be subracted from overall cost of camp.
CAMPER INFORMATION
Camper's Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade Entering in the Fall:*
Numbers Only
Camper Age at Time of Camp*
Numbers Only
Camper Gender*

MaleFemale
Which week of camp is the camper attending? (Choose all that apply)*

Junior Week 1Junior Week 2Sports, Music, & DramaWork & Wilderness
Camper Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What Church do you regularly attend?
Preferred Cabin Mate(s)
(Can choose more than one)
PARENT/GUARDIAN INFORMATION
Parent #1 Name*

First NameLast Name
Parent #1 Phone Number*
Please enter a valid phone number.
Parent #1 Email*
example@example.com
Would you like to sign up for our monthly newsletter?

YesNoAlready signed up
Parent #2 Name

First NameLast Name
Parent #2 Phone Number
Please enter a valid phone number.
Parent #2 Email
example@example.com
EMERGENCY CONTACT INFORMATION

Please add a non-parent family member who could act on your behalf for your child in the event that we cannot reach the parents in the event of an emergency.
Emergency Contact Name*

First NameLast Name
Relationship to Camper*
Emergency Contact Phone Number*
Please enter a valid phone number.
CAMPER PICK UP

If I, the parent or guardian, am not picking up my camper, one of the following has permission to do so.
Name

First NameLast Name
Relationship to Camper
Name

First NameLast Name
Relationship to Camper
AGREEMENTS & RELEASES
MEDIA MARKETING RELEASE: I give Camp ACCOVAC permission to use any photo/video of my camper taken while at Camp ACCOVAC for the purposes of marketing of the camp and it's ministry (brochures, newsletters, etc.)*

YesNo
OFF CAMPUS ACTIVITIES RELEASE - I hereby claim that I am the legal parent or guardian of the above named camper. I give permission for my child to participate in off-site activities. This form my photo copied (or reprinted) for use by Camp ACCOVAC outside of Camp ACCOVAC.*

YesNo
CAMPER CONDUCT AGREEMENT - I agree that my child will abide by all rules of behavior and conduct at Camp ACCOVAC and understand that violating these rules may result in expulsion from camp and that any physical property damaged will be charged to me as the parent.*

Yes
Please type your full name as a form of signature, verifying that you agreed or disagreed to the above statements.
MEDICAL QUESTIONAIRRE
If your camper will need to take any medications during our week of camp, please bring them with you in the appropriate container (no unmarked containers or baggies) and turn them in to the nurse upon arrival and complete the dosage form and release form for medication distribution.

The following information must be filled out with the most accurate information available!
Please list all known allergies (including food, seasonal, medication, or other) and any physical limitations (diabetes, asthma, heart disease) that your camper may have: (if none, put N/A)*
Please list any activities that should be limited or avoided (if none, put N/A)*
Please list any medications or inhalers your child currently takes that he/she will need to take at camp: (if none, put N/A)*
If your camper were to need any over the counter medication for any reason, we have a camp nurse who will take care of that. Please choose which of the following options you would prefer:*

Please give medicine as neededCall me firstPlease do not give my camper any medication
Please list any medications your camper cannot take: (if none, put N/A)*
Medical Insurance Carrier
Policy/Group Number
AUTHORIZATION/AGREEMENT FORM
I hereby claim that I am the legal guardian and that the health information that I have provided is accurate and that the person herein described has my permission to engage in all activities except as otherwise noted. I hereby give permission to the medical personnel selected by the Camp Coordinator to order tests, and treatment in the event I cannot be reached in an emergency. I hereby give permission to the Physician selected by the Camp Coordinator to hospitalize, secure proper treatment for and and to order injection and/or anesthesia and/or surgery. I understand that my own insurance is primary before Camp ACCOVAC’s insurance. Additionally, this form may be photocopied to be used outside Camp ACCOVAC if necessary.
Sign this form by typing your full name below:*

First NameLast Name
Reminder:

Please make all checks payable to Camp ACCOVAC and mail them to:

Brandon Clemons

33021 Mountain Valley Rd.

Millboro, VA 24460
Should be Empty:

CAMP ACCOVAC

CAMPER INFORMATION

PARENT/GUARDIAN INFORMATION

EMERGENCY CONTACT INFORMATION

CAMPER PICK UP

AGREEMENTS & RELEASES

MEDICAL QUESTIONAIRRE

AUTHORIZATION/AGREEMENT FORM