HEART OF VIRGINIA COUNCIL For Council Use:
ARROHATTOC DISTRICT Acct. Code
CUB SCOUT DAY CAMP
July 31 – Aug 4, 2012 Scout Registration Form
Registration Deadline: Friday, June 15, 2012
• MUST complete an Annual Health and Medical Record form (parts A & B).
Scout Information: (PLEASE PRINT CLEARLY AND FILL OUT COMPLETELY)
Age at July 25, 2012 _________ Rank as of Sept 2012 ________________
First Name: ________________________ Last Name: _________________________ Pack #: _______
Emergency Contact Name: ______________________________ Relationship: ____________________
Phone #: ___________________________
Please indicate below a phone number and email address for general camp related contact information (ie- severe
weather causing camp to close, reminders about camp, etc)
Name: ____________________________________ Phone #: ______________________________
[Email—preferred contact] __________________________________________________________________
T-shirts will NOT be guaranteed if application is received after the Registration Deadline.
Circle shirt size: Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult XL
CUB SCOUT AGREEMENT: (CUB MUST READ, UNDERSTAND AND SIGN)
Upon signing this Agreement…
I will follow the Buddy System while in Camp. I will know where my Buddy is at all times.
I will not leave Camp, while Camp is in session, without the Directors permission.
I will ask for permission from the Chaperone leader before I leave the Den.
I will not bring knives or matches to camp.
I will be respectful to all Staff members and all Chaperones.
I will be respectful and mindful of the feelings, safety and property of other campers.
Proper language will be used at all times.
I WILL HAVE FUN.
I have read and understand this Agreement, and I understand that failure to abide by these rules could lead to a
phone call to Parents or possible dismissal from Day Camp.
Scout’s Name: (print) _______________________________________
Scout’s Signature: _______________________________________
Parent’s Signature: _______________________________________ Date: _______________
For Pack Coordinator Use:
I will attend camp for _______ day(s) as a Cub (new Tigers, Wolves and Bears), Webelos (I or II)
I will attend on the following days:
FULL WEEK or ONLY the checked days:
Tuesday, Wednesday, Thursday, Friday, Saturday
For Office Use Only: Parent is a Chaperone Staff assigned to ____________________________
Free T-shirt & water bottle: Y N
Docs rec’d (list date) Reg Form: ________ Med Form: __________ DB Entry: _____________/_____