Camp Overlook Registration Form
- Please print this form and fax or mail it to us. -
- Have a group of 5 or more? To request a Group Discount Form contact the camp office (540)269-2267 -
Fax# (540)269-2267 same as the office #

				Participant's 	  	  	 
Last Name: ____________________ 	First Name : ____________________
Nick Name: ____________________ 	Gender : ____________________
Birthday: ____________________ 	Grade Completed ____________________
Height ____________________ 	Weight ___________________

Address 	  	  	 
Street: ____________________ 	City: 	____________________
State: ____________________ 	Zip: 	____________________
Parent or Guardian: ____________________ 	Home Phone: 	____________________
Family e-mail: ____________________ 	Emergency Phone: ____________________
Church Participant Attends: ____________________ 	District (Circle one): 	Winchester, Harrisonburg, Staunton
First Choice Event: ____________________ 	Date: 	____________________
Second Choice Event: ____________________ 	Date: 	____________________
Participants first time away from home for a week ? ____________________ 	Has participant attended Overlook before? ____________________
If participant wishes to be grouped with ONE friend of the SAME age and grade we will try to place them together. 	Friends name: 	____________________
  	
T-Shirt Size  (circle one)   10-12-Y,    14-16-Y,     S-A,     M-A,     L-A,     XL-A, 

Important or helpful infomation(e.g. allergies, fears, restrictions, etc.)     ___________________________________________________________________________ ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________

In signing this application, I hereby certify that the registrant is in good health and may participate in ordinary camping activities as noted above. I authorize the officials at camp to act in any emergency. In case of surgical emergency, I give permission to the physician selected by the camp to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for the participant. Should itbecome necessary for the participant to return home because of illness or other reason, I will abide by the camp's decision and provide transportation. I also give the camp permission to use pictures including the participant in camp publicity.

Parent/Guardian Signature: ____________________ 	Date: 	____________________

For office use only:
Housing: ____________________ 	Counselor: ____________________
Rec'd w/Reg: _______ Discount: _______ Scholar.: _______ Bal. Due: _______ Rec'd at Camp: _______

Complete for Visa / Mastercard Payment.
Cardholder's Name: ____________________ 	Amount $ ____________________
Address: ____________________ 	Credit Card #: ____________________
City, State: ____________________ 	Exp. Date: ____________________
Zip: ____________________ 	Payment is for: 	Deposit / Balance
Phone: ____________________ 	Camper's Name: ____________________

Address:
3014 Camp Overlook Lane, Keezletown, Virginia, 22832

**Registration cannot be accepted without $100.00 deposit ($50 refundable with 7 days notice prior to event)

Registrations are accepted on a first-come first-served basis.
A health form and suggested packing list will be sent with confirmation letter.
Confirmation of registration will be mailed after May 1, or
receive confirmation by e-mail directly!