NORTHERN VIRGINIA LIONS YOUTH CAMP, INC.

NVLYC Logo
REQUEST FOR USE
Name of Organization:

Arrival Date:

Departure Date:

Year
Sponsoring Lions Club:
Lions Club Contact: Event Type:

Organization's Responsible Person:

(This person to be on site during the entire event and will be sent the confirmation.)

Address:

City:

State:

Zip:

Phone Res:

Phone Bus:

Email:

No. Attending Youth:

Adult:

Total: (Limit 150 people total)

Facilities Requested: Check all that apply. * Denotes Occupancy limits.

Amphitheater

Bailey's Cross Roads Host Cabin (14)*

Clifton Cabin (22)*

Durant Hall (49) *

Durant Hall with Kitchen (49)*

Fauquier/Herndon Cabin (20)*

Pavilion

Park West Cabin (20)*

New Baltimore Cabin (12)*

Tent Camping Area # 1

Tent Camping Area # 2

Vienna Host/Engleside Cabin(18)*

Vienna Host Primitive Area # 1

Vienna Host Primitive Area # 2

Our insurance company requires that you provide a copy of your tour permit/council authorization for scouts; certificate of insurance for other groups. 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:
  1. Use of the camp requires a $100 refundable security deposit.
  2. Use of the camp and Durant Hall with kitchen requires a $200 refundable deposit, which must accompany your reservation. The security deposit will be refunded after the camp has been inspected by the caretaker and at the discretion of the Camp Board. Separate checks should be mailed to the scheduler.
  3. Friday and Saturday nights $5.00/camper/event.
  4. Sunday through Thursday or more than 2 nights of camping $5.00/person/night.
  5. Use of Durant Hall with the Kitchen $100/week for more than 2 nights of camping. Separate checks should be mailed to the scheduler.

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.

Organization's Representative Sign & Date: _________________________________________________

Organization's Representative Type or Print Name:

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

% Nancy Hetzel, Scheduler

865 Smith Rd, Charles Town, WV 25414-4634

FAX: 304-725-5088; E-mail: nvlyc@yahoo.com