2026 Bedford Adventure Camp Registration Form

2026 Day Camp

Days of Camp: June 30th, July 7th, July 14th, July 21st, July 28th, August 4th
Embark on a summer filled with adventure at the Bedford Adventure Camp. Each Tuesday of camp will bring a different adventure, from learning survival skills to participating in adventure activities like ziplining, rock climbing, and canoeing. We will even be inviting local experts to teach campers about their area of outdoor expertise.

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 Age
Camper Grade in 2026/2027
Bedford Adventure Camp is for rising 5th-8th graders.
Camper Swimming Ability
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?
How did you learn about Bedford Outdoor Adventures Camp?

Emergency Contact(s) & Authorized Pickup

List the name of at least one person who can be contacted in the event of an emergency or illness if a parent cannot be reached. Any person listed should be able to assist in contacting parent(s) of the child. 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
Format: (000) 000-0000.
Secondary Phone Number
Format: (000) 000-0000.
Relationship to Child
Is this contact over 18?
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?
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
Format: (000) 000-0000.
Secondary Phone Number
Format: (000) 000-0000.
Relationship to Child

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

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

Days of Camp

This camp will take place on Tuesdays from the end of June to the beginning of August. Camp will run from 9am-5pm each Tuesday.
Please select which days of camp your child will be participating in.

Tuesday, June 30th

$60.00

Tuesday, July 7th

$60.00

Tuesday, July 14th

$60.00

Tuesday, July 21st

$60.00

Tuesday, July 28th

$60.00

Tuesday, August 4th

$60.00

Enter coupon

Total

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:

2026 Day Camp