Staff App New

Name

First

Last

Date / Time

Email

Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Age

Church you attend and Pastors name.

New Staff (2 Years or Newer) Please give a brief testimony of your salvation.

Note

ALL STAFF MEMBERS MUST BE WILLING TO SUBMIT TO A BACKGROUND CHECK, THANK YOU FOR YOUR COOPERATION. WE LOOK FORWARD TO LABORING TOGETHER FOR THE CAUSE OF CHRIST WITH THE YOUTH ATTENDING GRACE BIBLE CAMP.

Have you ever been charged with child neglect or abuse?

Yes
No

Have you ever been convicted of any crimes against children?

Yes
No

1. Have you ever been convicted of or plead guilty to a felony?

Yes
No

3. Are you currently on probation or parole?

Yes
No

2. do you currently have any criminal action pending?

Yes
No

Other than the previous; is there any fact or circumstances involving you or your background that would call into question you being entrusted with the supervision, guidance, and care of young people?

Yes
No

Please give details for any yes answer.

I have read Camp Staff Orientation Information page.

Yes
No

Note

A picture of Staff Member will be taken at camp for Identification purposes and will be placed in staff files.

Emergency Contact

Family Physician.

Health Insurance Carrier

(Camp Insurance is secondary after primary insurance coverage).

Have you had a physical exam in the past 24 months?

Yes
No

Is your immunization and tetanus up to date?

Yes
No

Do you have any health conditions?

Do any allergies require an injection?

Yes
No

Permission & Agreement

I agree and give my permission

IN CASE of EMERGENCY: By signing this form I give my permission for the camp health supervisor to administer necessary medications and medical treatment for Camper [or Staff Member] while he / or she is attending Grace Bible Camp. I attest that all information on this form is correct.

Permission & Agreement

I agree and give my permission

I grant permission to Grace Bible Camp and Our Nawakwa, Inc., its agents, and its employees the irrevocable and unrestricted right to produce photographs and video taken of my child, myself, and members of my family while at Grace Bible Camp held at Camp Nawakwa or in connection with any activities for Grace Bible Camp and Our Nawakwa, Inc. for any lawful purpose including publication, promotion, illustration, advertising, trade, or historical archive in any manner or in any medium by Grace Bible Camp and Our Nawakwa, Inc. I hereby release Grace Bible Camp and Our Nawakwa, Inc. and its legal representatives from liability for any violation or claims relating to said images or video. Furthermore, I grant permission to use the statements of my child, myself, or my family members given during an interview or evaluation with or without my name for the purpose of advertising and publicity without restriction to time limit or geographic area. I waive my right, my child’s rights, and my family’s rights to any and all compensation stemming from the use of these materials.

Registration / Health Form and all monies must be received by Camp Registrar 7 days prior to Camp Week for camper to attend camp.

Staff Signature

Date