Youth Camp Staff Registration Form

Please complete and send to yourYouth Camp Director.You may want to make a copy of the completed form for your records.

CAMP SELECTION
Name of Camp:
REGISTRATION INFORMATION
Name: / Home Congregation (if applicable):
Full Mailing Address:
Cell Phone: / Email Address:
What information are you willing to have included in the logbook? (Check all that apply.)
Mailing Address Cell Phone Email Address
EMERGENCY INFORMATION
Emergency Contact: / Emergency Contact Phone:
Name of Physician(s): / Physician(s) Phone:
Name of Insurance Carrier(s): / Insurance Policy Number(s):
MEDICAL INFORMATION
(Confidential: Directors, please destroy all medical information after the close of camp.)
Please list below if you have medical conditions we need to be aware of(include such conditions as severe allergies, asthma,diabetes,seizures, etc.):
Are you taking medication? (If so, listmedication and dosage taken here, or attach a list with this form. Please Note: Your medication must be stored in a safe, secure location away from the campers while camp is in session.)
Special dietary needs (List what):
I hereby give my permission to receive emergency care. In an emergency, the information contained in this document may be released to qualified medical personnel.I certify that I am submitting my signature electronically by typing my name:
XSignature: / Date:Click here to enter a date.
STAFF COVENANT
As a staff member for this youth camp, I covenant to:
  1. Model Christian values as proclaimed in the Good News of Jesus Christ and described in the Community of Christ Enduring Principles.
  2. Participate fully in the life of the camp, which may vary based on my staff role. This means that I will live by the rules, schedules, and purposes of the camp. I will also live by the health, safety, and property care rules of the campground.
  3. Be fully present. Therefore, I will limit my use of electronics, including the use of cell phones and social media.
  4. Not possess or use tobacco products, marijuana, alcohol, or illegal drugs at camp.
  5. Dress in an appropriate way that maintains personal dignity and the dignity of the campers and other staff.
  6. Respect the worth of all persons. This means that I will respect the campers and staff by using appropriate language, handling conflicts with care, affirming others, embracing diversity, and modeling healthy interactions with all.
  7. Follow the direction and leadership of the Camp Director. When I disagree or have alternative suggestions, I will share them with camp leadership in a time, place, and way that are appropriate.
  8. Complete all tasks in a timely manner as has been requested by camp leadership.
  9. Respect and follow the policies and procedures of staffing a youth camp as outlined in the Registered Children & Youth Worker Training, as well as in the Youth Camp Staff Manual.

I certify that I am submitting my signature electronically by typing my name:
X Signature: / Date: Click here to enter a date.
NOTICE
The Greater Pacific Northwest (USA) Mission Center photographs and videotapes portions of our events to enhance the effectiveness of our communications to our current members and as an outreach tool in communities our Mission Center serves. We may use this technology in a variety of ways that may include the preparation and distribution of DVDs and posting all or portions of our events on our website. We are providing this notice so that you are aware of this activity. Participation in our events presumes your permission for us to use your image in future communications. If you have questions, comments or concerns, please feel free to contact the Mission Center President or Financial Officer.