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*

MonthDayYear
Date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email

Confirmation Emailexample@example.com
Phone Number*

Area CodePhone Number
Gender:*

MaleFemale
Birth Date*

MonthDayYear
Date
T-Shirt Size*

Youth SYouth MYouth LAdult SAdult MAdult LAdult XLAdult 2XLAdult 3XLAdult 4XL
Which camp(s) are you interested in? Select all that apply*

Winter Junior RetreatServe WeekendFirst Chance CampJunior CampMiddle School CampHigh School CampFamily CampWomen's RetreatYoung At Heart RetreatRental GroupsGeneral/off-seasonOther
Which position(s) are you interested in?

CounselorCIT (counselor in training)Worship/musicActivities/recreationLifeguardKitchen/food serviceHousekeepingMaintenance/groundsCheck-in/office supportGeneral volunteerOther
Please select any of the following certifications, licenses, or other training you have:*

CPR/first aidLifeguard certificationDriver's licenseFood handler's permitNone of theseOther
Please select any of the following skills or interests that you have:*

CraftsTeaching/preachingSkits/dramaVideo/photographyGuitarPianoDrums/rhythmSingingLeading sports and field gamesHikingOther
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 revealed Himself 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?*

NoYes
Has someone ever accused you of abusing a child?*

NoYes
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 note that the information you provide will be shared with the program directors, camp nurse, and/or food service director as needed.
Please list any allergies your student has to food, medications, or environment that you would like us to know about.*
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.*

YesNo
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.*

YesNo
Parent/Legal Guardian Name:*

First NameLast Name
Parent/Legal Guardian Email*

Confirmation Emailexample@example.com
Parent/Legal Guardian Phone Number*

Area CodePhone Number
Today's date:*

MonthDayYear
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