YMCA Camp Kekoka Camper Application

YMCA Camp KekokaP.O. Box 580 • Kilmarnock, VA 22482
Telephone: (804) 435-3616 • Fax: (804) 435-2227
E-mail: campkekoka@peninsulaymca.org

Camper Information
Camper Name:

A value is required.		 Name Called:

A value is required.		 Sex:

Please select an item.
Home Address:

A value is required.
City:

A value is required.		 State:

Please select an item.		 Zip:

A value is required.Invalid format.
Home Phone:

A value is required.Invalid format.		 Current Email:

Invalid format.
Birth Date:

A value is required.Invalid format.		 Rising Grade Level:

A value is required.		 Name of School:

A value is required.		 Camper's Age:

A value is required.
*If possible, my camper would like to have the following cottage mate:
(Cottages are assigned by age and grade level. Cottage requests must be mutual.)
Has this Camper attended Kekoka before?
Please select an item.
How did you hear about Camp Kekoka?
A value is required.

*The camp administration believes meeting new friends and experiencing diversity is an integral part of the camp experience. Camp Kekoka reserves the right to determine cottage mate placement.

Parent / Guardian Information
Parent/Guardian 1 Name:

A value is required.
Home Address:

A value is required.
City:

A value is required.		 State:

Please select an item.		 Zip:

A value is required.Invalid format.
Home Phone:

Invalid format.A value is required.		 Work Phone:

Invalid format.		 Cell Phone:

Invalid format.		 Email:

A value is required.Invalid format.
Parent/Guardian 2 Name:
Home Address:
City:

 State:

 Zip:

Invalid format.
Home Phone:

Invalid format.		 Work Phone:

Invalid format.		 Cell Phone:

Invalid format.		 Email:

Invalid format.
Emergency Contact if Parent's / Guardian's can not be reached:

A value is required.
City:

A value is required.		 State:

Please select an item.		 Zip:

A value is required.Invalid format.
Home Phone:

A value is required.Invalid format.		 Work Phone:
Invalid format.		 Cell Phone:

Invalid format.		 Email:

Invalid format.

Strong Communities Campaign:

Families may wish to make a tax-deductible contribution to Camp Kekoka's scholarship campaign. Camp Kekoka is a branch of the Peninsula Metropolitan YMCA, a non-profit organization which puts Christian principles into practice through programs that build healthy spirit, mind and body for all. Money raised goes toward assisting children and families in need in the community. It is our goal to make all YMCA programs accessible to everyone. Your donation will allow a child to have an unforgettable experience at Camp Kekoka. Consider lending your support, and help build strong kids, strong families and strong communities.

Yes, we would like to contribute:

Please make a selection.

Please read and complete the following:

Application and admissions:
I hereby request that my child be accepted to attend YMCA Camp Kekoka. I understand and am aware that my child will be participating in many physical activities and that the potential for accidents does exist. In consideration of acceptance to Camp Kekoka:

  • I indemnify and hold harmless Camp Kekoka, The Peninsula Metropolitan YMCA and/or its staff from any and all liability, claims, damage, injury or illness sustained by my child, and
  • I grant permission for Camp Kekoka to provide or obtain medical attention for my child in the event of sickness or injury, and I understand accident insurance is not included in the camp fee. Should a camper require special medical treatment, prescriptions, or hospital care during the camp session, parent(s)/guardian(s) shall bear the expenses.
  • I agree that Camp Kekoka may photograph and/or video tape my child for use in promotional materials.
  • I understand that as a registered Camp participant, my child may be leaving Camp Kekoka property in YMCA vehicles to area destinations for specialized programs.
  • I understand that my child may be participating in the following activities: archery; skateboarding; rollerblading; basketball; flag football; arts & crafts; motor boating; swimming; sailing; kayaking; field sports; soccer; softball; volleyball; paddle boats; and environmental challenge.

I understand that a current Health Form must be submitted to the camp office in order for my camper to participate. Download the Parent Packet for complete information including contact and what your camper should bring to camp.

Applicants who cannot be accepted due to a full session are notified and advised to select another session or join a waiting list. Cancellations do occur, and waiting list campers advance in the order applications are received. To help you prepare more effectively for your child's camp experience you can down load a parent guide from www.peninsulaymca.org under the registration tab.

Admission as a Camp Kekoka camper carries many privileges and responsibilities. We expect campers to participate in the total life of camp-- to work, play, worship and live together. We do not allow the use of tobacco, alcohol, illegal drugs, or weapons (other than equipment provided for camp activities under staff supervision).

Application signifies understanding and acceptance of these responsibilities-- violators will be dismissed without a refund. In addition, should a behavior or discipline problem affect our work with other campers or their enjoyment of Camp Kekoka, we reserve the right to dismiss those campers responsible, without refund.

Name A value is required. Date A value is required.Invalid format.

Please make a selection.

All you need to know about my camper:

Enter appropriate words that describe your camper or add your own: my camper is excited, nervous, caring, trusting, enthusiastic, energetic, shy, responsible, positive, etc.
 
A value is required.Exceeded maximum number of characters.

Goals that you have for your camper:
 
A value is required.Exceeded maximum number of characters.

Expectation for camper's counselors:
 
A value is required.Exceeded maximum number of characters.

Any other information the counselors need to know about your camper (bed wetting, allergies, medication, special needs, etc.)
 
Exceeded maximum number of characters.

Thank you for filling in this information; it is very helpful to our counselors so they can better serve your child.
Mission: To put Christian principles into practice through programs that build healthy spirit, mind and body for all.

Admin | Webmail

Peninsula Metropolitan YMCA • 101 Long Green Boulevard • Yorktown, VA 23693
Phone: (757) 223-7925 • Fax: (757) 223-7926 • E-mail: info@peninsulaymca.org

Web site design: Web Development Technology Partners, inc.