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Camp Request Form - Spring Break

April 11th, 12th & 13th from 9am - 4pm

Adult Contact Information

First Name
Last Name

Address Line 1
Address Line 2
ZIP/Postal Code

First Name
Last Name

First Name
Last Name

Release Agreement

By completing this registration process you are acknowledging that the parent or legal guardian of the child or children attending the Lynchburg Humane Society Spring Break Camp has read, understood and agrees to this waiver.

I give permission for the Lynchburg Humane Society to use photos of the child attending Spring Break Camp for Lynchburg Humane Society marketing and other materials. I do hereby forever release, acquit, discharge, and hold harmless the Lynchburg Humane Society, its officers, trustees, agents, employees, representatives, successors and assigns for all manner of claims, demands, and damages of every kind of nature whatsoever which the undersigned or said minor may now or in the future have against the Lynchburg Humane Society, its trustees, agents, employees, representatives, successors or assigns on account of any personal injuries, physical or mental condition, known or unknown, to the person of said minor and the treatment thereof, as a result of or in any way growing out of the acts of the Lynchburg Humane Society, it’s officers, trustees, agents, employees, representatives, successors or assigns, including but not limited to their negligence, in rendering the services above described or in any way incidental thereto.

If you would like to still register a child for camp but do not agree to the use of photography, please proceed with your registration and call Taylor Reinson at 434-448-0088 Ext.116 or email at  to let us know that you would not like to have your child's photo used.

Refund policy:  Every effort will be made to accommodate enrollment changes based on session capacities. 

If you are registering more than 2 children please submit a separate form.