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Resend Confirmation
Wilderness Week - 2022
June 15th - 17th
What do you want to pay today?
Check one:
*
Full Amount ($100.00)
Camper Information
Camper Name
*
Date of Birth
*
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
3
4
5
6
7
8
9
10
11
12
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14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Gender
*
Male
Female
Current Grade (2022)
*
(Choose One)
6th
7th
8th
9th
10th
11th
12th
Tshirt Size
*
(Choose One)
Adult Small
Adult Medium
Adult Large
Adult XLarge
XX Large
Camper is an immersed believer
Yes
No
Church Camper Attends
*
(Choose One)
Altavista Church of Christ
Cool Spring Christian Church
Cornerstone Church of Christ
County Line Christian Church
Forrest Hill Christian Church
Friendly Christian Church
Green Bay Christian Church
Horsepasture Christian Church
Kenbridge Christian Church
Lynchburg Church of Christ
Mayo Christian Church
Mt. Ivy Christian Church
Mt. Pleasant Christian Church
Mountain View Christian Church
Museville Christian Church
North Danville Church of Christ
Oak Grove Christian Church
Oak Ridge Christian Church
Public Fork Christian Church
Rich Acres Christian Church
Salem Church of Christ
Sandy Bottom Christian Church
Sheva Church of Christ
Stella Christian Church
South Danville Church of Christ
Stone Memorial Christian Church
Traditional Christian Church
Whitmell Christian Church
Willow Oak Christian Church
None
Other
Mountain Mission School
First time at Camp Pitt
Yes
No
Who can pick up camper? Camper will ONLY be released to a person on this list
*
Is anyone restricted from picking up or having contact with camper?
*
Yes
No
Medical Information
Health Insurance Provider (indicate "none" if no insurance)
*
Insurance Policy No. (indicate "none" if no insurance)
*
Group No. (indicate "none" if no insurance)
*
Does the camper have any current or past medical conditions?
*
(Choose One)
Yes
No
Is the camper allergic to or have any adverse reaction to any of the following:
Medication
*
(Choose One)
Yes
No
Food
*
(Choose One)
Yes
No
Plants
*
(Choose One)
Yes
No
Insect bites/Stings
*
(Choose One)
Yes
No
Are any medications being brought to camp?
*
(Choose One)
Yes
No
Is camper RESTRICTED from fully participating in recreational/sports activities?
*
Yes
No
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