NORTHERN VIRGINIA LIONS YOUTH CAMP, INC.

Departure Date:

Organization's Responsible Person:

Address:

State:

Zip:

Phone Res:

Phone Bus:

No. Attending Youth:

Adult:

Total: (Limit 150 people total)

Bailey's Cross Roads Host Cabin (14)*

Durant Hall with Kitchen (49) *

Pavilion

Tent Camping Area # 1

Tent Camping Area # 3

Warrenton Sunrise Cabin (8)*

Our insurance company requires that you provide a copy of a "Certificate of Insurance". This needs to be in the hands of the camp scheduler before your request can be confirmed. The user's fees must be in the hands of the camp scheduler one week before the start date of your event.

User/Camping Fee Schedules:

Use of the camp requires a $100 refundable security deposit: refunded (by applying to the camping fee) if no destruction is incurred at the camp: forfeited if destruction is incurred at the camp. The caretaker will inspect the camp after the outing and report the finding to the camp board for their decision..

1. Use of Durant Hall to include kitchen requires a additional $100 security deposit which must accompany your reservation. The security deposit will be refunded (by applying to rental fee) if no destruction is incurred to Durant Hall. The caretaker will inspect Durant Hall after the outing and report the finding to the camp board for their decision.
2. Camping Fees are $5.00 per night per camper.
3. Campers will need to bring mattresses (if desired) as they are not provided in cabins.
4. Kitchen and Toilet supplies, i.e. soap, toilet tissue, and hand towels, etc, must be provided by the camping group.
5. Kitchen and Toilet supplies i.e. soaps, toilet tissue and hand towels etc must be provided by the camping group

I have read and understand the above rules of the Northern Virginia Lions Youth Camp, Inc. and agree to these rules. I will be in attendance at the Northern Virginia Lions Youth Camp, Inc. and will be responsible for the youth and adults present. Further, as the authorized representative of the organization using the facilities and grounds of the Northern Virginia Lions Youth Camp, Inc. (also referred to as the Youth Camp), I agree that my organization shall indemnify and hold harmless and defend the Youth Camp, its members, officers, employees and authorized representative against any liability for any suits, actions or claims for injuries or damages of any character arising from or relating to the use by my organization or its employees, agents or representatives of the land, improvements or facilities of the Youth Camp.

Note: The day before your scheduled visit to the Youth Camp notify the camp scheduler with the number of campers attending your event.

Organization's Representative Sign & Date: _________________________________________________

Organization's Representative Type or Print Name: __________________________________________

Print and mail with checks to: NORTHERN VIRGINIA LIONS YOUTH CAMP, INC.

% Phil Schrack, Scheduler

3568 Sutherland Court, Warrenton, VA 20187 3971

E-mail:NVLYCI@gmail.com