Short-Term Facility Use Form

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SHORT-TERM FACILITY USE FORM
Blue Ridge Scout Reservation
Camp Powhatan
Blue Ridge Mountains Council
P.O. Box 7606
Office: 540-265-0656
Roanoke, VA 24019-0606
Fax: 540-265-0659
PLEASE READ:
1.
All applications and fees must be submitted at least two weeks prior to your arrival. Reservations are only official
when a Council designee signs this application.
2.
Groups must have a signed Facility Use Form and Tour Permit when checking in with the Ranger or Campmaster
3.
If you have scheduled to use facilities requiring a certification, plan to present your card at check-in.
4.
Camp check-in time must be listed below and checkout time is no later than 2:00 on Sunday.
5.
All groups must follow the guidelines described in the Reservation Rules and Policies Publication. This guide can
be downloaded from our website.
Please check with Ranger before building fires.
Pack/Troop/Crew/Post # __________________ District: ____________________________________________
Arrival Date/Time: ____________________________ Departure Date/Time: ____________________________
Number of Adults: ________ Number of Youth: _________
(Coed groups require adult male and female leadership)
Purpose of this Event: ________________________________________________________________________
Trip Leader: _________________________________ Age: _____ Scouting Position: ___________________
Address: ___________________________________________________________________________________
Street
City
State
Zip
Work Phone: ________________________________ Evening Phone: _________________________________
Fax # to return confirmation: ___________________________ Email: _________________________________
Assistant Tour Leaders Name: ____________________________________________ Age: ________________
It is understood that this camping trip will be conducted in accordance with the camping standards of the Boy
Scouts of America and the rules established in the Reservation Rule and Policies Publication and the Guide to
Safe Scouting. As trip leader, I understand that a registered adult leader must be in charge during our entire stay
at camp and I will assume responsibility for our group abiding by those policies. I also understand that all
facilities must be left in the same or better condition than found.
Group Leader Signature: _________________________ Date: __________________
Approved by: _________________________ Title: _______________ Date: _________
Fees Collected: _____________ (receipt attached; Cost Center 176)
Payments may be mailed to the Council Service Center or billed to a Credit Card
Council Stamp
Type of Card: ________ Amount: ________ Account: ________________________ Exp. Date: __________
Print name as shown on card: ____________________________ Signature: _____________________________
Blue Ridge Mountains Council
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Last Updated: 1/31/11

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