Camp Staff Registration CHOOSE YOUR CAMP Children's - 3rd – 6th grade June 9-13 Youth - 6th – 12th grades June 2-6 Whoa 1 - Ages 9-12 June 15-18 Whoa 2 - Ages 13-18 June 18-21 Child * First Name Last Name Age Social Security Number Driver's License Number State Issued Cell Phone Number Email Address Address Address 1 Address 2 City State/Province Zip/Postal Code Country Which camp(s) and why do you want to work in this camp HEALTH REGISTRATION Are you (camper) under the guardianship of the court, government agency or foster ? Yes No Please check if you have had a history of any of the following, (any medical history?) Asthma Heart trouble Sinus trouble Ear trouble Bed wetting Diabetes Frequent colds Allergies Athletes foot Upset stomach Kidney trouble Sleepwalking Epilepsy Emotional difficulty If Allergies are checked, please specify to what Please List Any Medications Authorization to use these over-the-counter meds: Ear Drops Eye Drops Ibuprofen Tylenol Antacid Dietary restrictions: Activities that should be restricted Family Doctor Name & Phone Number In case of Emergency, I understand that the people listed above will be notified if possible and I hereby give permission to the Physician selected by the Camp Director to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child (or myself) as named above. NOTE: Laclede Baptist Camp insurance is a secondary insurance. The camper’s insurance is primary insurance. Name of camper’s insurance Phone Number / Policy Number / Group Number How long have you been a Christian Have you ever led anyone to Christ? Yes No Do you share your faith regularly with the lost? Yes No Are you willing to learn how? Yes No Position of interest Please check your talents and abilities that can be useful at camp Crafts Bible Study Puppets Nature study Special music Lifeguard Music leading Devotion Leading Nurse Other FREE STAFF T-SHIRT* IF your registration is in the association office before noon, MAY 19TH. (If we are not in the office – you can put your form in the metal box outside to the right of the front door). We cannot be responsible if you, or your church, do not get your registration form in our office on time. Church / Pastor's Name / How Long Attended REFRENCES First Name Last Name Phone (###) ### #### First Name Last Name Phone (###) ### #### First Name Last Name Phone (###) ### #### Have you ever been formally accused of child abuse or molestation? Yes No To your knowledge, have you ever been involved in a situation that could lead to criminal charges being filed against you? Yes No Do you use alcohol products? Yes No Do you use any tobacco products? Yes No Will you attend staff training, as set by camp director, before camp? Option 1 Option 2 Can we use your picture in a brochure? Option 1 Option 2 Because of increased litigation to churches and non-profit organizations such as our associational camp, we need your permission to do a background check Option 1 Option 2 I understand that a ‘background screening report’ may include information from public or private sources regarding my character, driving records, criminal history, court records (both civil and criminal), and/or other information relevant to my volunteer service may be obtained in connection with my application as a volunteer with Laclede Baptist Camp. Option 1 Option 2 I understand that, if I am approved for volunteer service by Laclede Baptist Camp, this background check authorization will be kept on file and may be used at any time during my service to procure further information when, in the judgment of Laclede Baptist Camp, such may be necessary. Option 1 Option 2 I hereby release and discharge to the extent permitted by law, Laclede Baptist Camp, its employees, any individual or agency obtaining information for Laclede Baptist Camp, and any personal or professional reference, from any and all claims, damages, losses, liabilities, costs, or other expenses arising from the retrieving, reporting and/or disclosure of information in connection with this background investigation. Option 1 Option 2 I understand that I am volunteering my services and declare in no way shall I be considered an employee or subcontractor or independent contractor of Laclede Baptist Camp. Option 1 Option 2 I have read, understand and consent to the above. I further authorize that a photographic copy or a telephonic facsimile of this document shall be valid for purposes present and future. My signature below certifies that all information I have provided in connection with this background check is true, accurate and complete to the best of my knowledge. Option 1 Option 2 I hereby authorize a background screening for abuse, molestation, neglect or a criminal record: Option 1 Option 2 Thank you!