Sheriff's Summer Youth Camp Registration Form

Sheriff's Summer Youth Camp Registration Form

June 14-18, 2026
INSTRUCTIONS: Please provide complete and detailed health information to help determine appropriate supervision, support, and accommodations for the Page County Sheriff’s Office (PCSO) Sheriff’s Summer Youth Camp. This form must be signed by a parent or legal guardian.

If the participant has a disability and requires assistive devices, services, or other accommodations to participate, please contact Sgt. Derrick Beahm at 540-843-4108 during business hours at least seven (7) days prior to the camp to discuss arrangements.

MEDICATION POLICY: No medications will be administered or distributed without a valid prescription issued by a licensed physician.
Youth Information
Name*

First NameLast Name
Phone Number*
Shirt Size*
Date of Birth
Age
Grade (RISING 5th-7th)*
School Name
Home Address*

Street Address

Street Address Line

CityState

Postal / Zip Code
Parent/Guardian Information
Parent/Guardian Name*

First NameLast Name
Relationship to Participant*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address (if different from Participant)
Street Address
City
Email
example@example.com
Primary Custodian*

First NameLast Name
Emergency Contact 1
Emergency Contact Name*

First NameLast Name
Mobile*
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Email
example@example.com
Relationship to Participant*
Emergency Contact 2
Emergency Contact Name

First NameLast Name
Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Relationship to Participant

Registration confirmation
Yes
Should be Empty:

Sheriff's Summer Youth Camp Registration Form

Youth Information

Parent/Guardian Information

Emergency Contact 1

Emergency Contact 2

Medical Details

Registration confirmation