2022 PB & J Adult Staff Application

PB and J Adult Staff Application

Read the announcement sheet below in full before proceeding. This has all requirements listed for the application to be complete.
Name

First Name Last Name
Email Address
example@example.com
Home phone number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell phone number

Area Code Phone Number
Male Female
Date of Birth
Adult T-Shirt Size

Small Medium Large XLarge XXLarge
Medical Permission Form
Name

First Name Last Name
Phone Number

Area Code Phone Number
Alternate Phone Number

Area Code Phone Number
Emergency Contact

First Name Last Name
Emergency Contact Phone Number

Area Code Phone Number
Physician Name

First Name Last Name
Physician Phone Number

Area Code Phone Number
Medical Payment Responsibility

Insurance Individual
Insurance Company and Policy Number (if none type none)
Food allergies (if none type none)
Special Health Concerns (if none type none)
Drug Allergies (if none type none)
Asthma

Yes No
Inhaler

Yes No
ALL Current Prescription Medications (if none, type none)
NOTE: If participant is taking prescription medication regularly, please bring a supply in the original prescription bottle in the name of the participant. This will be turned over to medical staff for dispensing and kept in the medical station. It is the responsibility of the participant to go to the medical station to take his/her medication as directed by the prescription.
Medical Procedure Acknowledgement

Clear
Waiver of Claim/Media and Medical Release
Waiver of Claim/Media and Medical Release
NOTE: All attachements within this form will be sent to your email after submission for your further review.
Date

Month Day Year
Date
Name

First Name Last Name
Signature

Clear
Date

Month Day Year
Date
Website Updates

We are now going to put your bio and head shot on the website for parents to get to know you a bit better. This should really make a good connection with campers.
Short Bio Describing you for the website
Upload a Head shot to include with your bio

Browse Files

Cancel of

Background Check and ID upload

You will be receiving an email closer to camp to complete a background check. This will be for all staff this year regardless of previous background checks. If you are unable to make camp and background check has been completed, you will be responsible for the $50 fee.
Copy of Government Issued ID (this is required every year) *

Browse Files

Cancel of
AFFIDAVIT

I, the Applicant named in this application hereby swear or affirm that during the past year I have not been convicted of, charged with, nor am I under investigation for crimes described below. In the event I have been convicted of, charged with or am under investigation for such crimes, I have provided a written explanation.

Criminal homicide, assault, stalking, kidnapping, unlawful restraint, sexual assault, indecent exposure, endangering welfare of children, corruption of minors, sexual abuse of children, including but not limited to possession or transmission of child pornography, or the attempt, solicitation or conspiracy to commit any of the offenses set forth in this paragraph.
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

PB and J Adult Staff Application

Medical Permission Form

Waiver of Claim/Media and Medical Release

Website Updates

Background Check and ID upload