Student (Under 18) Staff Application

Student Staff (17 and younger) Questionnaire

Thank you for applying to serve at Pleasant Valley Christian Camp! Please answer all questions below.
Application Date *

Month Day Year
Date
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email Address *
Gender: *

Male Female
Birth Date *

Month Day Year
Date
T-Shirt Size (Adult)

XS S M L XL XXL XXXL
Which camp(s) are you interested in? Select all that apply *

Winter Kids' Retreat Serve Weekend First Chance Camp Junior Camp Middle School Camp Family Camp Young At Heart Retreat Rental Groups General/off-season
Which position(s) are you interested in? *

General Volunteer (Worship Leader, Program Team, etc) Counselor Counselor In Training (CIT) Worship/music Speaker Activities/recreation Lifeguard Kitchen/food service Housekeeping Grounds/maintenance Check-in/office support
Please select any of the following certifications, licenses, or other training you have: *

CPR/first aid Lifeguard certification Driver's license Food handler's permit None of these
Please select any of the following skills or interests that you have:

Crafts Teaching/preaching Skits/drama Video/photography Guitar Piano Drums/rhythm Singing Leading sports and field games Hiking
Please provide a personal reference who can tell us more about you. List first and last name, phone number, and email address.
Do you consider yourself to be a Christian? Please describe what that means to you.
In the last year, how has God shown up in your life?
In what areas are you seeking to grow in your faith and/or personal development?
In what ways can we be praying for you and encouraging you?
Please provide the name of your pastor and the church you attend. Include a contact phone number. *
Please list any experience you have working with children. Include the positions, organization names, contact names, and phone numbers.
Screening Questionnaire

Because Pleasant Valley Christian Camp desires to protect children in our care, please answer the following questions. We understand that the answers to these questions may be private and deeply personal - and we will protect your privacy.
Why do you want to work with children in this ministry? *
Do you have a preference concerning the age or gender of children with whom you work? *
Have you ever physically or sexually abused a child? *

No Yes
Has someone ever accused you of abusing a child? *

No Yes
I authorize Pleasant Valley Christian Camp to contact all individuals, organizations, and references listed on this application form to verify the information I have provided. I agree to release from liability any person or organization that provides information concerning me, including those persons I have listed as references and contacts from my previous work with children. **Please Type your name and today's date to sign your application** *
Parental Permission and Medical Information

Please have your parent/legal guardian answer the following questions.
Please list any allergies your student has to food, medications, or environment. *
Please list any medical conditions your student has that you would like us to know about. *
Please list your student's insurance information including insurance company name, policy number, and contact number. *
Please list any medications your student takes. *
Please list at least two emergency contacts (including yourself). Include first and last names, phone numbers, and relationships to the child. *
Permission to treat: I hereby give permission to medical personnel to provide routine health care; to administer prescribed medications; and to administer emergency treatment for my child, including, but not limited to X-rays, routine tests, treatment and/or hospitalization; and to provide or arrange necessary related transportation for my child. I also agree to the release of any records necessary for treatment, referral, billing or insurance purposes. It is my intention that representatives of the camp be considered 'personal representatives' for the purpose of disclosing health information that is protected under the Health Insurance Portability and Accountability Act of 1996. I also agree to the disclosure to camp representatives of protected health information of the minor named herein in order to provide information related to the person's ability to participate in camp activities; and to provide information to the camp representatives to keep me informed of my child's health situation. In the event that I cannot be reached in an emergency, I hereby give permission to the medical personnel selected by the camp director to secure and administer treatment, including hospitalization, for the named person. This completed form may be photocopied for trips out of camp. *

Yes No
Photo Release: I hereby grant permission for my child to be video taped and/or photographed while participating in programs and activities of Pleasant Valley Christian Camp. I understand that video taping and photographs will be used for educational, training and promotional purposes only. *

Yes No
Parent/Legal Guardian Name: *

First Name Last Name
Today's date: *

Month Day Year
Date
BY SUBMITTING THIS REGISTRATION, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Should be Empty:

Student Staff (17 and younger) Questionnaire