Please select the week you wish to serve at Camp BASIC this year: (*)
Week One: Sunday June 9 - Saturday June 15, 2013 Week Two: Saturday June 15 - Friday June 21, 2013
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If you can not serve at camp for the entire selected week, which days of the selected week will you be able to serve?
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
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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: (*)
male female
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Parent/Guardian Name(s):
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Have you ever volunteered at Camp BASIC before? (*)
Yes No
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If so, when?
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Have you ever been convicted of a crime, other than a minor traffic ticket? (*)
Yes No
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Indicate what volunteer position you are interested in: (*)
Counselor Helper (volunteers who are not confirmed, i.e. under 13 years) Nurse Kitchen help (Week 2 Only) 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 Adult 3XL Adult 4XL
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Church Information
Are you baptized: (*)
Yes No
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Are you confirmed: (*)
Yes No
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Church Name:
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Synod Affiliation:
WELS ELS Other
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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? (*)
Yes No
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If Yes, please describe the type, what you did, and length of stay:
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Have you ever worked with individuals who have a developmental disability?
Yes No
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If Yes, please describe:
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Describe any special training you may have:
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Please check off any special Interests that could be used at Camp
Leading Devotions Acting in Skits Directing Skits Organizing/leading camp activities Leading Camp Singing Teaching Crafts
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Are you willing / able to:
Push a camper in a wheelchair? Help a camper with toileting needs? Work with an autistic camper?
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What instrument(s) do you play?
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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 guarding First Aid CPR First Responder Other
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If Other, please list for us your other certifications
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Do you have any food allergies or diet restrictions? (*)
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May we release any of the following information to other volunteers and starf?
E-mail Address Phone Number Home Address
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Any other information 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 that 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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(today's date)
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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(today's date)
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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(today's date)
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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(today's date)
Are you a human?
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