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STAGE PAIDPermit No. 4McCOY, VA24111Blue Ridge Christian Camp, Inc.P.O. Box 428McCoy, VA 24111(540) 639-9147BRCC'S 2012 INFORMATION& REGISTRATION FORMDIRECTIONS TO BRCCFrom Interstate 81:Take Exit 118B towards Blacksburg and Virginia Tech. Follow signs for Blacksburg andRoute 460 West Bypass. Stay on Route 460 West Bypass and take the second Price's ForkRoad exit. Stay on Price's Fork Road for approximately 3 miles. Turn right onto Route652/McCoy Rd. and go 5 miles. Look for camp sign on the right. Turn left onto SterlingDrive and take the first gravel road on the right to the camp.From Radford/Pulaski County:From Fairlawn, take Rt. 114 East past the Radford Arsenal. Turn left at next traffic light onto Rt. 685 (Prices Fork Road).Stay on 685 for 3.1 miles. Turn left onto 652/McCoy Rd. and go 5 miles. Look for camp sign on right. Turn left ontoSterling Drive and take first gravel road on the right to the camp.ASSOCIATIONBlue Ridge Christian Camp, Inc., a 501(c)3 non-profit organization, is owned and operatedby the Churches of Christ/Christian Churches of SW Virginia. Campers are accepted atBRCC regardless of race, sex, religion, age, color, or national origin.

BRCC 2012 Registration and Health Information FormEVENT FOR WHICH YOU ARE REGISTERING:9 Teen Ministry (June 10-16)9 Middle School 1 (June 17-22)9 Senior High (June 24-29)(check or circle one)9 Junior 1 (July 1-6)Charlie Brown (July 8-10)9 Snoopy (July 12-13)9 Day Camp (July 14)9 Middle School 2 (July 15-20)9 Junior 2 (July 22-27)Please print in ink.Have you attended BRCC before? [ ] yes [ ] noCamper's NameHave you been immersed? [ ] yes [ ] noAddressMother's name and work phone:City State ZipPhone ( ) Date of BirthFather's name and work phone:Sex Age Grade, Fall 2012Home ChurchEmergency Contact (non-parents -- give name, relationship, andMinister or Youth Ministerphone):PARENT/GUARDIAN: The person(s) or organizationnamed to the right has my permission to pick up the campernamed on this registration following his/her stay. I understandthat my child will be released ONLY to the person(s) ororganization listed on this form and that I must call the camp ifthis is to be changed.Approved:Signature of Parent or GuardianIF YOU ARE RECEIVING FINANCIAL ASSISTANCE FROM YOUR CHURCH: You must have an authorized representativefrom your church (such as a minister, elder or treasurer) to sign below. Otherwise, the full tuition fee is due on the date of registration.(Church) will pay (exact dollar amount) of camper’s tuition/fees.Signed PositionIF YOU ARE SENDING THIS FORM PRIOR TO CAMP: In addition to the basic tuition fee for attending camp (see schedule),you may also (at your choice) include pre-payment for other optional camp expenses listed below. The optional costs may also bepaid on registration day. See registration instructions for further details. Please indicate the breakdown below:I am sending the required for tuition fee (or 50% deposit if sent by June 2)At my choice, I am also including: for Bland Scholarship Fund (to help other campers - see info) for camp T-shirt ( 12) for camp picture ( 5) for canteen (up to 12) for missions offering (any amount) is the total I am sending.(Please do not staple check to form.)FOR OFFICE USE ONLYFeeDepositChurch has paidChurch will payBalance due on registration dayBalance paid on (date)

Health InformationInsurance Company [] If "None"Policy/Group NumberDoes your insurance require a referral? [] Yes[] NoThis form must be accompanied by a copy of both sides of your health insurance card. In the event of an emergency,hospital personnel will ask us for this. See registration instructions for an important insurance clarification.Family Doctor Phone ( )Immunizations -- please U where current: [] Measles [] Tetanus, last booster in year (MUST be current)Health History - Please note and explain any special or likely conditions including, but not limited to, diabetes, asthma,headaches, bed wetting, seizures, skin rashes, earaches, sleepwalking, heart trouble, or other physical limitations.Allergies (including foods, drugs, bee stings, etc.):Emotional or behavioral problems (explain):Prescription medications brought to camp (kinds, dosages, frequencies):Any recent exposure to contagion? (specify):i BRING ALL MEDICINES IN THEIR ORIGINAL PRESCRIPTION OR OTC CONTAINERS iALL MEDICATION MUST BE LEFT WITH AND DISPENSED BY THE CAMP HEALTH OFFICER.SIGNATURESI hereby give permission to the physician selected by BRCC to hospitalize, secure proper treatment for, and to order injections, anesthesia, or surgery for the childnamed on this form. I understand, however, that every effort will be made to contact me in case of such an emergency, and if possible, before any such medicaltreatment is administered. I also give the BRCC health officer permission to give routine, non-surgical treatment.Unless otherwise stated, I hereby give permission for my child to participate in all activities including the ropes course/climbing wall and I have read the sectionbelow entitled "Agreement to Participate: Assumption of Risk and Release". I hereby release Blue Ridge Christian Camp from any responsibility other than normalsupervision and care. In case of accident, I will not hold Blue Ridge Christian Camp, or its staff members, management, or officers liable. I also give permission formy child's photo (unidentified) to be used in camp publicity, including the camp website.Additional for those attending Teen Ministry Week: As the custodial parent/guardian of the camper named on this form, I hereby give consent for my child toparticipate in Teen Ministry Week and to be transported to any off-campground activities.Signature: Date:(parent/guardian)NO, I do not give permission for the child named on the reverse side to participate in the ropes course (other permissions still apply).CAMPER’S SIGNATURE: "I understand that the main purpose of the camp is to help me grow spiritually and that the rules of the camp are based on Christianvalues. I have read the "General Camp Rules" and agree to abide by them fully."Signature of camper:Agreement to Participate: Assumption of Risk and ReleaseThe Challenge Course is an activity-based program that has been used successfully at BRCC to build teamwork and promote trust. Groups range from summercamp, sports teams, leadership teams, corporations, civic and church youth groups and many others. I understand that during the said activities that the applicant isrequested to participate in, that certain risks and dangers may occur. These include, but are not limited to the hazard of depending on other people and being atvarious heights (0-40ft.), accident or illness in remote places without medical facilities, the forces of nature and travel by air, boat, automobile or other conveyance.The undersigned further recognizes risks may also include loss or damage to personal property, physical or psychological damage and/or injury not excluding fatalitydue to accidents which may occur, including accidents resulting from this challenge course experience or other type of outdoor activities. I further understand that inparticipating in the activities I am requesting to participate in, I will be exposed to elements of nature including inclement weather. I understand that myparticipation in the Blue Ridge Christian Camp program is entirely VOLUNTARY and that I may excuse myself from participation if I so desire.

REGISTRATION INSTRUCTIONSPRE-REGISTRATION: While registrations for each event will be accepted through registration day, pre-registration isstrongly encouraged and appreciated so that camp programs may be planned more effectively. Pre-registration may also ensureyour place at camp, since the maximum attendance for each camp session is 90.For summer events, notice that each event has a regular fee and a discounted fee(see schedule). In order to receive the discount, you must pre-register by June 2,2012 for each event you are attending. Here’s how:1. Fill out registration & health forms completely.2. Photocopy both sides of your health insurance card (if you are insured).Insurance Clarification: Primary insurance coverage is the responsibility of the camper’s family insurance. In otherwords, our camper's insurance begins where yours terminates. Our policy is valid only when your policy has beenextended to its limits. All doctor and hospital forms will be completed using patient’s name, home address and personalinsurance. In the event you have no personal policy, ours will provide coverage within its limits. No camper is to bebrought to camp ill. Camp insurance will not cover pre-existing illness or injury.3. Include 50% of the discounted fee for the event you are attending. See schedule for fees.Additional: As indicated on the registration form, you may also include payment for other camp-related items. All ofthese items are completely optional purchases. Camp T-shirt -- 12 for all sizes Camp picture – 5. Will be delivered on the last day ofcamp, or mailed for half-week or shorter camps. Canteen – to be open at designated times during the weekfor the purchase of candy, snacks and soft drinks. Ageappropriate spending limits are enforced. Spending forcanteen varies but a typical weekly amount is around 612. Missions offering – Mission this year will be a team fromTeam Expansion (teamexpansion.org). Freewill offeringsmay be accepted at missions time during the week, orgiven up front. Any unspent canteen money may also (atcamper's wish) be given to missions.If you choose to include payment for optional items,please give details as indicated on the registration form.Optional items may also be purchased on registration day.4. Assemble forms, copy of insurance card, and payment. Please do not staple any items together. Make checks payable toBlue Ridge Christian Camp. Refunds for no-shows will be made by request only. 10 of pre-registration fee is nonrefundable and no amount is transferable.5. Send all items to Blue Ridge Christian Camp, P.O. Box 428, McCoy, VA 24111. No confirmation notice will be sent.i PRE-REGISTRATIONS MUST BE POSTMARKED ii NO LATER THAN JUNE 2 iAFTER YOU PRE-REGISTER: Balance of fee will be due on registration day, unless alternate arrangements have beenmade through your church. Registration for each session begins at the times indicated on the schedule. Upon arrival at camp,proceed to the dining hall for check-in.IF YOU HAVE NOT PRE-REGISTERED: You may still register up through registration day at the regular fee. Fullpayment will be due on registration day unless alternate arrangements have been made through your church. Registrationtakes place in the dining hall.