2025 Bedford Outdoor Adventures Camp Registration Form

June 2-6, 2025
Calling all middle schoolers! Embark on the ultimate summer adventure with Bedford Outdoor Adventures Camp, designed to ignite the spirit of exploration and cultivate a love of the great outdoors. Nestled in the heart of nature, our camp offers a diverse range of activities that promise an unforgettable summer experience. Each day of camp will bring a different adventure, from learning survival skills to trying out The Peaks adventure activities like ziplining, climbing wall, ropes course, and canoeing to taking a daily dip in the pool. Cap out the end of the week with an (optional) overnight campout on Thursday night and family cookout (open to all camper family members) at 4 pm on Friday.

Location: The Peaks Retreat and Adventure Center, 1336 Simmons Mill Rd. Thaxton, VA 24174
Camper's Information
Camper Name*
Nickname
Date of Birth*

MonthDayYear
Camper's Age*
Bedford Outdoors Adventures Camp is for rising 6th-8th graders.
Entering Grade in 2025/2026*
Camper Swimming Ability*

Non-SwimmerBeginner Swimmer (can swim on front 20ft without flotation)Advanced Swimmer (can pass swim test)
Please provide any additional information that you think is important or may affect the camper's ability to fully participate in the camp program.
Does your child have experience with outdoor programs or spending time outside?

Parent Information

Parent/Guardian 1
Parent/Guardian 1*

First NameLast Name
Relationship to Child*
E-mail*
example@example.com
Cell Phone*
Home Phone
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent's Work/School Name*
Or enter N/A if not applicable
Parent's Work/School Phone
Where would you like to be reached while your child is at camp?*

Cell PhoneWork PhoneHome Phone
Would you like to input a second Parent Contact

YesNo
Parent Information

Parent/Guardian 2
Parent/Guardian 2

First NameLast Name
Relationship to Child
E-mail
example@example.com
Cell Phone
Home Phone
Home Address Same as Parent/Guardian 1?

Yes
Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Parent's Work/School Name
Or enter N/A if not applicable
Parent's Work/School Phone
Where would parent/guardian 2 like to be reached while your child is at camp?

Cell PhoneWork PhoneHome Phone

Emergency Contacts/Authorized Pickup

Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be within one hour of the center/home, able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age. The first emergency contact must live no more than 1 hour away and be over the age of 18.
Emergency Contact #1
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone Number*
Secondary Phone Number
Relationship to Child*
Is this contact over 18?*

YesNo
Your first emergency contact must be over 18 years of age. Please enter another contact.
Does this contact live more than one hour away from The Peaks Retreat and Adventure Center?*

YesNo
Your first emergency contact live within one hour of The Peaks Retreat and Adventure Center. Please enter another contact.
Emergency Contact #2
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone Number*
Secondary Phone Number
Relationship to Child*

Health/Dietary Information
Does your child have any special health or medical conditions or any food, medication or environmental allergies?*

YesNo
Please explain*

0/150
Does your child have any dietary restrictions, including those for medical, religious or cultural reasons?*

YesNo
Please explain*

Camper Registration Fee

Bedford Outdoor Adventures CampJune 2-6, 2025, 8:30 am – 5:00 pm

$300.00

Enter coupon

Total

$0.00

The Peaks Retreat and Adventure Center has permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment. The emergency transportation service will determine the facility to which my child will be transported.*
Type first and last name above to consent
Sign Document*
Date Signed*

MonthDayYear
Should be Empty: