2018 -JESUS CAMP STAFF APPLICATION AND MEDICAL RELEASE FORM

GOD IS GOOD MINISTRIES OF DALLAS, INC.

JESUS CAMP STAFF APPLICATION

June 20th - June 25th 2020

(Dates vary depending on role)

ASSUMPTION OF RISK AND RELEASE OF LIABILITY AGREEMENT

AUTHORIZATION FOR MEDICAL TREATMENT AGREEMENT

MEDICATION AUTHORIZATION AND RELEASE AGREEMENT

We are requiring applicants to pay $75.

If under 18, application must submitted by parent/guardian.

Note: Counselors/Jr. Counselors must agree to the "Counselor Responsibilities and Agreement" statements on this application.

Full Name of Applicant *

First Name Middle Name Last Name

Birth Date *

Month Day Year

Current Age *

Gender *

Phone Number *

Area Code Phone Number

Applicant's Email *

Put "N/A" in blanks that are not applicable.

Parent or Guardian if under 18 *

First Name Middle Name Last Name

Parent or Guardian Email if under 18 *

If 18 and older, use your own e-mail.

Parent or Guardian Phone Number if under 18 *

Area Code Phone Number

Name of Emergency Contact *

Relationship *

Emergency Contact Phone Number *

Area Code Phone Number

2nd Emergency Contact Name *

2nd Emergency Contact Phone Number *

Area Code Phone Number

Choose one *

Your Address *

Street Address

Street Address Line 2

City State

Zip Code Country

How would you like to serve at Jesus Camp? *

Do you need a ride to Jesus Camp? *

Note: This question should be answered accurately or you may not have a ride to camp. It is 90 miles to camp from DFW area. If you need a ride to camp, you will be required to meet at a designated location in the DFW area. Any questions should be directed to dale@jesuscamp.org.

Is there anything you would like to share about yourself? *

T-Shirt Size

Have you received certification in any of the following? *

CPR First Aid Life Guard Nurse EMT None of the above

Are you a Christian? *

Yes No

COUNSELOR RESPONSIBILITIES AND AGREEMENT:

I am a Christian. I have committed my life to God. I believe there is only one way to God through Jesus.
I commit to showing love to God through praising God, listening to God, seeking God and reading his word at camp.
I commit to loving the campers and treating them with respect.
I commit to being a good Christian example.
I will be on time for meetings in support of the schedule.
I will have prayer time with my cabin at nights and in the morning.
I will point my campers to Christ through my actions, and through my words.
I will have prayer time with a prayer partner (co-counselor) daily.
If there are behavior problems in my cabin, I will notify leadership ASAP.
I will sleep when it’s time to sleep.
I will be a part of the activities and encourage my campers to participate.
I understand that anything that I bring to camp (money, jewelry, cell phone) could be stolen.
I will not check my phone or receive calls during events at camp.
I will sit with my cabin at meal times.

If you are applying for a counselor position, do you agree to follow the agreement listed above *

Yes No Not applying for counselor position

Have you committed your life to Jesus Christ? *

No Yes

What church do you presently attend? *

For how long? *

Why would you like to serve at Jesus Camp? *

Do you use illegal drugs? *

Yes No

Have you ever been convicted or indicted for any crime involving child abuse or molestation of a minor? *

Are you required by law to register as a sex offender? *

Have you ever been convicted of a violent crime? *

Is there any fact or circumstance involving you or your background that would call into question your being entrusted with the care of children? *

Do you believe that the scriptures of the Old and New Testaments are the word of God, fully inspired by God? *

Do you believe there is no other way to be saved, except through Jesus? *

I will provide $150 for Jesus Camp to operate this year: *

Does applicant have any allergies to prescription drugs or non-prescription drugs? *

No Yes

If yes, please describe: *

Does applicant have any food allergies? *

No Yes

If yes, please describe: *

Does applicant have an inhaler? Note: Two inhalers should be brought to camp. *

No Yes

Do you take any medications? *

Yes No

Special note about medication:

Please note that if applicant will be bringing ANY medications to camp, including all prescription, over-the-counter and herbal remedies, the following rules will need to be followed:

1. All medications must be in their original packages. i.e. prescriptions in the prescription bottle, Tylenol in the Tylenol bottle, herbs in the bottle that they were originally bought in.

2. All medications must be accompanied by written and signed instructions for administration (the prescription on the bottle will be fine unless doses or times have changed).

3. Any nonprescription bottles must have the applicants name written on them and prescription bottles must be for the applicant.

If yes, please list the medication, reason for taking, and any side effects you may experience. *

Had any recent injury, illness or infectious disease? *

Yes No

If yes, please list: *

Have you had any serious illness, injuries, or medical operations in the last three years? *

Yes No

If yes, please describe, and indicate whether there are continuing side effects or limiting issues: *

Ever passed out during or after exercise? *

Ever have dizziness or chest pains after exercise? *

Ever had high blood pressure? *

Have a chronic or recurring illness/condition? *

Ever had frequent ear infections? *

Have problems with sleepwalking? *

Ever have seizures? *

Have diabetes? *

Have asthma? *

Ever had emotional difficulties for which professional help was sought? *

If yes, please list: *

Insurance Company *

Policy or Group Number *

Policy Holder Insurance ID#: *

Policy Holder's Name *

Policy Holder's Date of Birth *

Date

Insurance Phone Number *

Insurance Company Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Pastor's Name

First Name Last Name

Pastor's Phone Number

Area Code Phone Number

ASSUMPTION OF RISK AND RELEASE OF LIABILITY AGREEMENT

AUTHORIZATION FOR MEDICAL TREATMENT OF A MINOR AGREEMENT

MEDICATION AUTHORIZATION AND RELEASE AGREEMENT

WHEREAS, THE UNDERSIGNED (the applicant) wishes to be accepted for participation in all activities conducted by GOD IS GOOD MINISTRIES OF DALLAS, INC. (hereafter called “GIG”). In consideration of, and for the right to participate in such activity by GIG, its Directors, Officers, Trustees, Employees, Agents, and/or Associate, I have and do hereby assume all of the risks and any other ordinary risk incidental to the nature of the activity.

Further I will hold GIG, its Directors, Officers, Trustees, Employees, Agents, and/or Associate harmless from any and all liability, actions, causes of action, debts, claims, and demands of every kind and nature whatsoever, whether for bodily injury, virus transmission, property damage or loss, medical bills, hospital bills, and doctor bills, or otherwise, which the participant now has or which may arise from or in connection with participation in any activities arranged for me by GIG, its Directors, Officers, Trustees, Employees, Agents, and/or Associates, and their heirs, executors, and administrators, successors and assigns and for all members of my family, including any minors accompanying me. I fully understand that my physical activity involves risk of injury. I also understand that my participation in any activity is entirely VOLUNTARY. I enter into this activity and take full responsibility for the decision to participate or not to participate and agree to follow all safety instructions.

I do hereby release GIG, its Directors, Officers, Trustees, Employees, Agents, and/or Associate any liability whatsoever (including acts of negligence) arising out of an injury, damage, death, or loss, whether physical, mental or emotional, which may be sustained to the applicant, during the course of applicant’s involvement with this camp or any overnight camping before the camp session or after the camp session. I consent to the use and display of photographs (possibly on the internet) of the applicant.

I hereby agree that all health history is correct and complete as far as I know and the person herein described has permission to engage in all camp activities except as noted. I understand that applicant may be sent home if Camp rules are not followed.

Medications: I give permission to camp staff to administer "over-the-counter" medications and/or prescription medications (listed above, or prescribed during camp) to the applicant. I give authority and consent for GIG to treat applicant for a headache, fever, or upset stomach with the appropriate non-prescription medication such as Ibuprofen, Acetaminophen and Pepto-Bismol.

Emergency Medical Authorization: I consent for emergency medical treatment to be administered to the applicant by a licensed Physician, Nurse, Adult Staff Member or other emergency medical personnel. I hereby give permission to medical personnel to order X-rays, routine tests, and treatment for applicant. I hereby give permission to the Physician to hospitalize, secure proper treatment, order injections and/or anesthesia and/or surgery. I hereby authorize transportation to a medical facility by ambulance or other transportation if it is deemed necessary.

I further authorize the release of the above medical information to appropriate medical personnel and/or the health coverage insurance company. I agree that I am responsible for all medical expenses incurred in the event of a sickness and/or injury.

Background Investigation: I hereby authorize GIG to investigate applicant’s background and qualifications for purposes of evaluating whether applicant is suitable for the staff position. I understand that GIG may or may not utilize an outside firm or firms to assist it in checking such information, and I specifically authorize such an investigation by information services and outside entities of the company's choice. I also understand that I may withhold my permission and that in such a case, no investigation will be done, and the application will not be processed further.

Application Approval

I understand that my signature on this form constitutes a legal digital signature approving application. I understand that I must be a parent or legal guardian if I'm signing for a child under the age of 18. I have read this application and approve. By signing below, I hereby agree to the "ASSUMPTION OF RISK AND RELEASE OF LIABILITY AGREEMENT, AUTHORIZATION FOR MEDICAL TREATMENT AGREEMENT, MEDICATION AUTHORIZATION AND RELEASE AGREEMENT" including all statements listed on this application.

Today's Date *

Date

Digital Signature 18 and over. If under 18, parent must sign. Note: Use Computer mouse or finger to sign on a mobile phone. *

Signature Name (typed) *

Driver's License Number or Social Security Number *

Enter the message as it's shown. *

Medical History