2026 Village Initiative Spring Break Camp Registration Form

Village Initiative Spring Break Camp Registration

Camp hours are 7:30am - 5:30pm. Payments: Electronic payments, Zelle: thegreaterwaverly@gmail.com (Thomas Gilbert), Cash, or Money Order due March 30, 2026
Please select option(s):*

Spring Break April 6-10, 2026 - $45/week per childSibling discount - $35/week per childDay by Day - fee $20/per day
Camp Skills: Please select 2 options:*

Art - coloring and paintingCrafts - beads, strings, and glitterSports - Flag Football, Can Jam, Kickball
Camper Name
Name*

First NameLast Name
Gender*

MaleFemale
Birth Date*

MonthDayYear
Current Grade*
Camp Skills: Please select 2 options for #2 Camper :

Art - coloring and paintingCrafts - beads, strings, and glitterSports - Flag Football, Can Jam, Kickball
#2 Camper Name

First NameLast Name
Gender

MaleFemale
Birth Date

MonthDayYear
Current Grade
Camp Skills: Please select 2 options for #3 Camper:

Art - coloring and paintingCrafts - beads, strings, and glitterSports - Flag Football, Can Jam, Kickball
#3 Camper Name

First NameLast Name
Gender

MaleFemale
Birth Date

MonthDayYear
Current Grade
Camper's Information
Address*
City*
State*
Zip*
Parent or Legal Guardian Information
Parent/Legal Guardian*
Relationship to Camper*
Cell Phone*
Work Phone
Parents Email *
example@example.com
Emergency Contact Name(if parent or guardian is unavaliable)*
Emergency Number*
Relationship to Camper*
Health Information

A health officer is on site at all times.
It is our policy to contact the parent or guardian as soon as possible in the event of a serious accident or injury. If the information has changed after the day of registration please see the health officer at that time. Please bring all medication in ORIGINAL CONTAINER or you will not be allowed to leave the medication or vitamins at the camp. No exceptions. All prescriptions must be in that campers name and the correct dosage.
Are vaccines up to date?*

YesNo
All fields are required below. If nothing applies, please put "NONE" in the box. Thanks.
Any activity the camper should be restricted from?*
Any physical, mental or other condition that would require special attention or medication while at camp?*
List any allergies (ex: bees,peanuts, dairy)*
Any dietary needs that we should know about?*
List all medications, both prescribed and over the counter, all medications will be turned into the health officer except rescue inhalers, bring all medication in original containers.*
Physician's Name *
Physician's Phone Number *
Camper Release
Camper Release (List anyone, including parents, to whom your camper can be released)*
Terms and Conditions
- I understand payment is due on Tuesday, April 1 or prior to camp starting.
- I understand my child may not attend a camp session until payment in full is received.
- I understand The Village Initiative Summer Camp reserves the
  right to terminate a child's enrollment for any reason inconsistent with
  the rules of the camp. In the event of such termination, no refund of
  tuition will be made.
- I understand completed medical and emergency forms must be on
  file at The Village Initiative Summer Camp prior to my child
  attending his/her first day of camp.
By hitting submit and putting your initials, you agree that you are the parent or legal guardian of the above named camper, and are over the age of 18. In case of medical emergency or general medical care, I give consent for medical teatment for the aboved named camper by authorized personnel. I understand that the above named camper will only be released to the names listed above, an update may be done at registration. I certify that my child has my permission to attend camp and participate in all activites. I authorize The Virtual Village Initiative to use my camper's picture, testimony, and video in any promotional material(web,print,or media).

I have carefully read and agree to the above terms and conditions.
Electronic signature, please initial*
Camp Fees
prevnext( X )
#1 Camper Weekly Fee
$45.00 Quantity
Item subtotal:$0.00

Check for Additional CampersEnter the number of additional children
$35.00 Quantity

Total

$0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Should be Empty:

Village Initiative Spring Break Camp Registration

Camper Name

Camper's Information

Parent or Legal Guardian Information

Health Information

Camper Release