Summer Camp Registration

NC West Youth Camp 2026

Please fill out the following information to confirm your registration. If you are registering multiple children, please submit one form per child.
I am registering for:
I am:
Please select the one that applies:
Church Name (ordered by city)
Is there another student coming to Camp that your child would like to be in the same cabin with? If so, list the name(s) here. If not, leave this box blank. *This is a suggestion — not a guarantee.
Student Full Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Gender
Student's T-Shirt Size (Adult Sizes)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I would like to receive text message updates at the number listed above.
Student's Email Address
example@example.com
Student's School
Grade Completed This Year ('25/'26 School Year)
Emergency Contacts and Insurance Information

Fill out the information below as accurately and completely as possible.
Emergency Contact (Parent/Guardian) Name #1

First NameLast Name
Emergency Contact (Parent/Guardian) Phone Number #1
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact (Parent/Guardian) Email #1
example@example.com
Emergency Contact (Parent/Guardian) Name #2

First NameLast Name
Emergency Contact (Parent/Guardian) Phone Number #2
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact (Parent/Guardian) Email Number #2
example@example.com
Insurance Company
Policy Number
Member Name
Allergies (if student has no allergies, please type "None" in the box below)
Medications being taken (if student is not taking medications, please type "None" in the box below)
Please list any current or past medical conditions that our Medical Staff should be aware of in the course of care for your child while at Camp. Please also include any conditions that may affect their involvement in strenuous or athletic activities (if there are none, please type "None" in the box below).
Medical Release and Consent

Fill out the information below as accurately and completely as possible.
In the event of a medical emergency, I do hereby give my permission for the responsible leader, adult sponsor, or staff member of Victory Mountain Camp/NC East District Wesleyan Youth Staff to make any necessary medical decisions regarding treatment for my son/daughter without the necessity of notifying me, and do further agree to hold blameless any physician, hospital, or medical center for rendering such services. I do understand that if an emergency should occur, every effort will be made to contact me as soon as possible. By clicking the box below, you certify that you have read and agree to this consent:
Zip Line & Swing Participation Agreement

Name of sponsoring organization: Victory Mountain Camp, 3594 Youth Camp Road, Sophia, NC 27350 Name of Sponsor's Coordinator: Chad Brinkley 336-250-5993 Description of activity: Ropes Course, Ground to Ground Zip Line and Giant Swing
I acknowledge that participation in the activity described above involves risk to the participant (and to participant’s parent or guardian, if the participant is a minor), and may result in various types of injury including, but not limited to, the following: sickness, exposure to infectious/communicable disease, bodily injury, death, emotional injury, personal damage, and financial damage.In consideration for the opportunity to participate in the activity described above (the “activity”), the Participant (or parent/guardian if the participant is a minor) acknowledges and accepts the risk of injury associated with participation in and transportation to and from the activity.The participant (or parent/guardian) accepts personal financial responsibility of any injury or other loss sustained during the activity or during transportation to and from the activity, as well as for any medical treatment rendered to the participant that is authorized by the sponsor, its agents, employees, volunteers, or any other representatives (collectively referred to as the “activity sponsor”).Further, the participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the activity sponsor for any injury arising directly or indirectly out of the described activity or transportation to and from the activity, whether such injury arises out of the negligence of the activity sponsor, the participant, or otherwise.If a dispute over this agreement or any claim for damages arises, the participant (or parent/guardian) agrees to resolve the matter through a mutual acceptable alternative dispute resolution process. The dispute will be submitted to a three-member arbitration panel for resolution in accordance with therules of the American Arbitration Association.

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

NC West Youth Camp 2026

Emergency Contacts and Insurance Information

Medical Release and Consent

Zip Line & Swing Participation Agreement

Payment Amount