Please select the week you wish to serve at Camp BASIC this year: (*)
Week One: Sunday June 10 - Saturday June 16, 2012
Week Two: Saturday June 16 - Friday June 22, 2012

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Personal Information

Full Name: (*)

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Street Address: (*)

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City: (*)

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State: (*)

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Zip Code: (*)

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Phone Number (*)

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E-Mail:

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Age: (*)

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Birth Date mm/dd/yyyy (*)

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Gender: (*)
malefemale
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Parent/Gaurdian Name(s):

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Have you every volunteered at Camp BASIC before? (*)
YesNo
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If so, when?

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Have you ever been convicted of a crime, other than a minor trafic ticket? (*)
YesNo
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Indicate what volunteer position you are interested in: (*)
Counselor
Helper (volunteers who are not confirmed, i.e. under 13 years)
Other

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If you checked "Other" above, please tell us what position:

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What is your T-Shirt Size?
Child Small
Child Medium
Child Large
Adult Small
Adult Medium
Adult Large
Adult XL
Adult XXL

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Church Information

Are you baptized: (*)
YesNo
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Are you confirmed: (*)
YesNo
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Church Name:

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Synod Affiliation:
WELSELSOther
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If you checked "Other" above, please indicate:

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Church City:

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Church State:

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Pastor's Name:

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Pastor's Phone:

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Previous Camp Experience

Have you ever attended or volunteered at a camp? (*)
YesNo
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If Yes, please describe the type, what you did, and length of stay:

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Have you every worked with individuals who have a developement disability?
YesNo
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If Yes, please describe:

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Describe an special training you may have:

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Please check off any Special Skills & Interests that cold be used at Camp
Leading Devotions
Plays & Skits
Life Guard
Teach and Lead camp songs
Athletics
Crafts

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What instrument(s) do you play?

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Can you lead people in singing? (*)
YesNo
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Can you describe for us any other special skills and interests?

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Current Red Cross or other Certification:
Life guardingFirst AidCPRFirst ResponderOther
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If Other, please list for us your other cirtifications

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May we release any of the following informaiton to other volunteers and starff?
E-mail Address
Phone Number
Home Address

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Any other informaiton the Camp Director should know about you:

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Releases To Be Checked by the Participant or the Participant's Guardian

The following releases must be checked and dated by the participant or the participant's guardian. If the releases are not checked, any participant who is a minor will not be permitted to attend Camp.


BY CHECKING THIS BOX, I AGREE to follow Camp rules and in the event of improper behavior I understand that I will be requested to leave Camp. I understand taht I am attending Camp as a volunteer and apart from room and board, there is no remuneration or payment. I understand that Camp BASIC is for the benefit of the campers, and I promise to treat each of them with the utmost respect and Christian love.
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(*)
Check this box if you are a counselor or helper
Check this box if you are a Parent or Guardian

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The Date of agreement for this conduct release (*)

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Photo/Public Relations Consent and Release


I understand that Camp BASIC may wish to use my/my child's name, photograph and / or stories with its work and that it needs appropriate consent to do so. Pictures may be taken for the purpose of sharing with the group, for sharing with area churches, the community and on the Camp BASIC web site.


BY CHECKING THIS BOX I HEREBY GIVE MY PERMISSION to Camp BASIC to use for volunteer recruitment, fund-raising and other communications purposes, photographs, films or audio recordings concerning myself/my child. I hereby warrant that I have full power to give this consent to this release.
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Participant's Name for Photo and PR Release:

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Parent's Name, if participant for Photo PR Release is a minor:

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Date you agreed to our Photo PR Release: (*)

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Authorization For Treatment


Authorization for the treatment of (Participant's Name): (*)

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You must check the box to grant the following permissions (*)
BY CHECKING THE BOX I GRANT PERMISSION TO the person herein described to engage in all Camp activities, unless noted otherwise. Authorization for Treatment: I hereby give permission to the medical personnel selected by Camp BASIC to order X-rays, routine tests, treatment, to release records necessary for insurance purposes, and to provide or arrange necessary related transportation for me or the above named participant. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by Camp BASIC to secure and administer treatment, including hospitalization, for the person named above.
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Date of Authorization for Treatment (*)

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Emergency Contact Information


Emergency Contact Participant's Name: (*)

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First Emergency Contact/Parent Information, please supply us with a name, address, city, state, zip, home phone, work phone, and cell phone. (*)

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Second Emergency Contact, please supply us with name, home phone, work phone, and cell phone: (*)

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For Participants who are minors:


Please be aware that Camp BASIC does not have trained medical professionals on staff. In the absence of a licensed nurse, Camp Directors will pass out requested over-the-counter medication. For this reason it is very important that all of you let Camp staff know what over-the-counter medications you will allow Camp staff to dispense.

If needed, which medicatons may your child take?
Antacid
Maalox
Aspirin
Antihistamine
Pepto-Bismol
Anti-diarrhea
Ibuprofen
Decongestant
Kaopectate
Milk of Magnesia
Tylenol/acetaminophen
Cough syrup/drops

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Any additional information concerning health or medications for this participant?

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Permission To Attend Camp BASIC

only for minors

Minor Participant's Name:

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BY CHECKING THIS BOX I GRANT PERMISSION for my son/daughter/ward to attend Camp BASIC and to participate in all Camp activities. I also give permission for Camp staff to dispense medication to my son/daughter/ward as detailed above or in a written statement given to Camp staff. I understand that there are not licensed and trained medical professionals on staff at Camp BASIC.
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Parent or Guardian of Minor who will participate:

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Date when permission was given for minor to participate:

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Are you a human?

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