STAFF INFORMATION & MEDICAL RELEASE, AND PASTORAL ENDORSEMENT INFORMATION

First name

Last name

GENDER

Date (MM/DD/YYYY)

ARE YOU 18 OR OLDER AT THE TIME OF VOLUNTEERING AT THIS CAMP?(required)

YES NO

IF YOU ANSWERED YES ABOVE PLEASE ANSWER THE FOLLOWING QUESTION, IF YOU ANSWERED NO PLEASE SELECT N/A

HAVE YOU ALREADY SUBMITTED YOUR NAME AND CONTACT INFORMATION FOR A BACKGROUND CHECK?(required)

YES NO N/A

IF YOU SELECTED NO TO THE PREVIOUS QUESTION GO TO THIS LINK TO SUBMIT YOUR INFORMATION FOR A BACKGROUND CHECK

ADDRESS

Phone

Email

IN CASE OF EMERGENCY CONTACT

IN CASE OF EMERGENCY CONTACT PHONE NUMBER

Do YOU have any Dietary Restrictions?
(required)

YES NO

Please List all Dietary Restrictions (Please enter NA if you answered No)

Do YOU have any Allergies? (BeeStings, Penicillin, Peanuts, Fish, Gluten Free, Non-Dairy, etc.)(required)

Yes No

Please List all Allergens (Please enter NA if you answered No)

Do You Have Health Insurance?(required)

Yes No

Medical Insurance Provider (Please enter NA if you answered No)

Medical Insurance Provider Phone Number (Please enter NA if you answered No)

Medical Insurance Group Number (Please enter NA if you answered No)

Medica Insurance ID Number (Please enter NA if you answered No)

Primary Care Provider Name (Please enter NA if you answered No)

Primary Care Provider Phone Number (Please enter NA if you answered No)

Medical Consent – I understand that if any accident or sickness should occur which requires emergency treatment, my private insurance will be considered the primary insurance. Any insurance coverage provided under The Church of God of Prophecy camp insurance is secondary coverage. The Church of God of Prophecy Youth Camp, Directors and Staff will not be held liable for any accident sickness or expense relating to the same. If I am rendered unconscious or in any way unable to make medical decisions for myself, permission is hereby given to the camp staff and/or physician to secure proper treatment for and/or hospitalization and to administer injections, anesthesia, surgery and/or other emergency treatment deemed necessary for me.

Choose one option (required)

I Agree (By checking this box, I confirm that I am the volunteer or the parent/legal guardian of the volunteer. I acknowledge that I have read, understand, and agree to the terms of the attached Release and Waiver of Liability. I understand that checking this box represents my electronic signature and is the legal equivalent of my manual/handwritten signature.) I Disagree

Please provide the name and phone number of your Pastor who we can talk to. We will have a conversation to get an endorsement for you to volunteer at this camp.

Pastor’s Name

Phone Number

✨ That’s it! Send it over and we’ll take care of the rest.

If you have any requests, comments or special instructions (i.e. cabin requests, food requests, etc.) please leave those here.

Message

Volunteer (By entering my name in the following boxes, I confirm that I am the volunteer. I acknowledge that I have read, understand, agree to the terms of the attached Releases and Waivers of Liability. I understand that all the information I have entered on this application are honest and true to the best of my abilities. I understand that entering my name in the following boxes represents my electronic signature and is the legal equivalent of my manual/handwritten signature.)

First name

Last name

Parent/Legal Guardian of Volunteer if they are under the age of 18 yrs old (By entering my name in the following boxes, I confirm that I am the participant or the parent/legal guardian of the participant. I acknowledge that I have read, understand, agree to the terms of the attached Releases and Waivers of Liability. I understand that all the information I have entered on this application are honest and true to the best of my abilities. I understand that entering my name in the following boxes represents my electronic signature and is the legal equivalent of my manual/handwritten signature.)

First name

Last name

*** If the volunteer is a minor and we don’t have the digital signature above this form will be considered invalid and will need to be resubmitted. ***

Today’s Date (MM/DD/YYYY)

Camp Kairos

STAFF INFORMATION & MEDICAL RELEASE, AND PASTORAL ENDORSEMENT INFORMATION

Thank you for your response. ✨