MISSISSIPPI DISTRICT UPCI YOUTH CAMP

ADULT WORKERS APPLICATION

Applications must be pre-approved.*

APPLICATION DEADLINE: MAY 15

Please indicate below the camp you are applying for and complete the application, supplying all information.

 Junior Camp (Ages 8-12)

 Teen Camp (Ages 12-14)

 Senior Camp (Ages 15-19)

NAME: ______AGE:______ MALE  FEMALE

ADDRESS: ______PHONE: ______EMAIL: ______

CITY: ______STATE: ______ZIP: ______

I would like to serve as:

Counselor  Dorm Head  Music Director  Nurse  Principal  Recreation Director

Security Personnel  Sound Technician  Teacher  Janitor  Maintenance  Grounds Keeper

PASTOR’S NAME: ______CHURCH: ______

1. Have you (applicant) ever been accused or convicted of child abuse or child molestation, inappropriate behavior toward or with a minor, sexual impurity, or immoral conduct with any person?  Yes  No

2. I have read the qualifications above. By my signature I affirm that if selected to serve, I will fulfill all responsibilities to the best of my ability, and will work in accord with the camp directors and staff workers.

3. I have read and agree to the legal/liability release statement below.

The undersigned participant agree to hold Mississippi District UPCI, its employees, officers and volunteers from any claims, damages, losses and/or expenses arising out of participation in camp activities and to assume all liability for any and all personal injury, bodily injury, illness or property damage that occurs as a result of participation in such activities. Signature of this agreement also warrants that participation in this camp is voluntary and that the participant and undersigned understand the inherent risks involved in the camp’s activities. The participant understands that these risks exist despite the camp’s safety precautions and procedures and the participant agrees to obey all rules and policies mandated by camp personnel.

The undersigned participant warrant that the participant is physically fit and able to participate in all camp activities and that there is and will be adequate health insurance coverage in force for the term of the camp workers attendance. The undersigned further verifies that the health insurance covers any and all accidents, injuries or illnesses that may result from participation in the camp activities and that the camp’s medical form has been completed, signed and dated.

The undersigned participant gives the Mississippi District UPCI and its representatives permission to provide emergency medical response and/or treatment as needed for any injury or illness that may occur while the participant is involved in camp activities and agree to release The Mississippi District UPCI and its representatives from all liability arising out of such treatment.

Applicant’s Signature: ______

Qualifications and Requirements for Staff Youth Camp Worker:

1. Junior Camp and Teen Camp counselors must be at least 21 years of age (Married if under 21).

2. Senior Camp counselors must be 25 years of age (Married if under 25).

3. Must be willing to serve under the supervision of the Camp Director and assigned Staff Leader.

4. Must remain on campus at all times, except for an emergency.

5. Must help manage the campers at all times during class, recreation, meals, and services.

6. Shall be responsible for an assigned area in dorms and at meals, recreation, and service time.

7. Children under the age of 7 years will not be allowed in dorms, even if parent is a Youth Camp Worker.

FOR PASTOR’S USE ONLY

Comments concerning above applicant: ______

______

*PASTORS PLEASE NOTE: Prior to recommending anyone for staff position, make sure they meet the requirements and qualifications as stated, especially those that relate to item #1.

As Pastor of this applicant, I recommend acceptance to the staff position requested.

Printed Name: ______Signature: ______Date: ______

SEND APPLICATION FOR PRE-APPROVAL TO THE ADDRESS BELOW

Youth Camp Workers Application

MS District UPCI

P. O. Box 1188

Raymond, MS 39154

*Only pre-approved applications are assured space in dorm and meals without charge.

On site applicants will be subject to a $25.00 meal fee and accepted only if space is available.

Revised 03/14/06