txac youth & young adult ministries early fall 2013 | Page 14

Counselor & Staff Application/Registration Form - Forest Glen Christian Camp THIS IS A LEGAL DOCUMENT 6th GRADE RETREAT - NOVEMBER 1-3, 2013
Full legal name:_______________________________ _______________________________ _____________________________
Last Preferred name Male/Female First Social Security Number Driver License # Middle State

_______________________________ ______ ____________________________ ________________________ ________

Home address:______________________________________ City:________________ State:______ Zip:__________ Birthdate:____________________ Home phone:( )____________________ Work phone:( )_____________________ Cell phone:( )__________________ Email: ________________________________ Adult T-shirt size: S, M, L, XL, XXL Emergency contact name:________________________________ __________ ____________________ _________________
Relationship Day phone # Night phone #

Name of Employer & Work Address:_______________________________________________________________________ Church membership: _____________________________________ __________________________________ _______________
Name of Church City District

Areas of church leadership/involvement:____________________________________________________________________ Expertise/talents you would offer to the camp (i.e music, crafts, athletics, small group leadership, etc.):_____________________________________________________ Prior experience with youth in church or camp setting:_______________________________________________________ Indicate first responder certifications you have (EMS, CPR, First Aid, etc.)___________ Date certified_____________ Date Safe Sanctuary Certified________________________ Name & phone # for reference check:_______________________________________________________________________ Please indicate any emotional, behavioral, or physical disabilities which may require special awareness. Your answer will not necessarily result in exclusion from camp. This information will be made available to camp coordinator, director, nurse, and registrar.
__________________________________________________________________________________________________________ Date of last Tetanus immunization: _______________.

List any allergies (medications, food, insects, etc.)__________________________________________________________________ List any special conditions, restrictions, or medications:
_____________________________________________________________ Physician:____________________________________________ Physician's phone #: ( )___________________________ ____________________________________________ _________________________ ( )___________________________
Health Insurance Carrier Policy # Phone #

Have you ever been charged or convicted of a felony crime, including deferred adjudication probation? Yes / No If yes, explain:________________________________________________________________________________________ By signing below I am hereby giving permission, in case of emergency, to the physician selected by the camp to hospitalize, secure proper treatment, and order injection, anesthesia, or surgery in my behalf. I also understand that this youth camp is tobacco free. I hereby state that all information given on this form is true and correct. Signature:_____________________________________________________ Date:_______________________ Sr. Pastor's Signature:_________________________________________________ Date:_________________________ My signature indicates recommendation of applicant for counselor based on personal knowledge of him/her and their qualifications. My signature also confirms applicant is Conference Safe Sanctuary Certified.