JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Splash Camp Online Registration Form 2024
Splash Camp is now accepting campers for the Waiting List.
Open to Ages 5-12
Camp Duration: June 17 - August 9
Camp Address: 509 Randolph Ave, Cape Charles, VA 23310
Lead Director: Noah Lewis, 757-678-6581
Contact us at (757) 331-0851 or
splashcampcc@gmail.com
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Child's Full Name
*
Your answer
Mother's Full Name
*
Your answer
Father's Full Name
*
Your answer
Legal Guardian's Full Name (If Different)
Your answer
Child's Age & Birth Date
*
Your answer
Parent/Guardian Email
*
Your answer
Would you like to be added to an email list regarding important Splash Camp updates?
Yes
No
Clear selection
I understand that there is a weekly participation fee and that fieldtrips may not always be included:
*
I Understand
Required
Please select each week you wish for your child/children to attend:
*
Week One: June 17 - June 21
Week Two: June 24 - June 28
Week Three: July 1 - July 5 (Closed July 4th)
Week Four: July 8 - July 12
Week Five: July 15 - July 19
Week Six: July 22 - July 26
Week Seven: July 29 - August 2
Week Eight: August 5 - August 9
Other:
Required
Acknowledgment of Week Commitment
*
Please Type Name and Today's Date Below:
Your answer
Consent and Liability Release Form for Church Activity SPLASH CAMP
*NOT A QUESTION*
Your answer
Participants Home Address
*
Your answer
Parent's Cell Phone Number(s)
*
Your answer
Parent's Home Phone Number (If You Have One)
Your answer
Name of Additional Emergency Contact
*
Your answer
Phone Number of Emergency Contact
*
Your answer
Relationship of Emergency Contact to Participant
*
Your answer
Please list the names of
ALL
adults allowed to pick up your child from camp:
(Any person not listed won't be able to pick your child up from camp UNLESS a written note is provided to the director from the parent/guardian prior to the pickup)
*
Your answer
Please select from the following T-Shirt size options for your child's field trip shirt:
Adult X-Large
Adult Large
Adult Medium
Youth Large (Adult Small)
Youth Medium
Youth Small
Clear selection
Insurance and Medical Information Below:
*NOT A QUESTION*
Your answer
Primary Physician's Name:
*
Your answer
Insurance Policy #:
*
Your answer
Primary Physician's Phone #:
Your answer
Insurance Group #:
*
Your answer
Insurance Phone Number:
*
Your answer
Primary Dentist's Name:
Your answer
Primary Dentist's Phone Number:
Your answer
Preferred Hospital:
*
Your answer
Please List Any Known Medical Conditions/Allergies:
*
Your answer
Please List All Current and Ongoing Medications:
*
Your answer
Parent/Guardian Agreement:
*
Please Type Name and Dates Below:
Your answer
Please select all that apply and explain in next question box:
Athletics or Athletic Limitations (Explain Below)
Watching movies rated ____ or above (Fill-in Below)
Being driven by someone younger than ____ years of age (Fill-in Below)
Swimming
Other:
Please explain/fill in any selected box options above in this answer box:
Your answer
Parent/Guardian Agreement:
*
Please Type Name and Today's Date Below:
Your answer
MEDIA WAIVER:
*
I consent to the use of any video images, photographs, audio recordings, or any other visual audio reproduction that may be taken of the youth during activities attended by them to be used or shown, as CCBC deems appropriate.
I DO NOT consent to this media waiver
Required
Parent/Guardian Agreement:
*
Please Type Name and Today's Date Below:
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
