STAFF INFORMATION & MEDICAL RELEASE, AND PASTORAL ENDORSEMENT INFORMATION

Name *

Gender *MaleFemale

Birthday *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal code *

Phone *0 / 10

Email Address *

Are you 18 years or older at the time of volunteering at camp? *YesNo

Have you already submitted your Background Check Submission Form? *YesNo

BACKGROUND CHECK SUBMISSION FORM

In case of Emergency Contact Name *

Emergency Contact Phone Number *

Do you have any dietary restrictions? *YesNo

Please List all Dietary Restrictions *

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

Please List all Allergens *

Do You Have Health Insurance? *YesNo

Medical Insurance Provider *

Medical Insurance Provider Phone Number *

Medical Insurance Group Number (Please enter NA if none) *

Medical Insurance ID Number (Please enter NA if none) *

Primary Care Provider Name *

Primary Care Provider Phone Number *

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 optionI 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 *

How would the Pastor like to be contacted via email or phone call? *Phone numberEmail

Pastor's Phone number *

Pastor's Email Address *

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

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.)

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.)

Name *

THIS VOLUNTEER FORM IS DENIED FOR CONSIDERATION

*** If on this form there was not medical consent for emergencies and/or Pastoral information was not provided, we are not willing to consider this volunteer candidate for our ministry***

Date *