Counselor Registration Form 2022

We are excited about your interest in the 2022 Youth Camp! Please take a moment to complete this registration form.

This completed and signed Counselor Registration and Participation Agreement constitutes a request on behalf of the Counselor named below to participate in a Youth Camp (“Camp”) sponsored by Grace Presbyterian Church and scheduled to take place at Pine Summit Christian Camp in Big Bear Lake, CA (“Pine Summit”), from Monday, June 13 through Thursday, June 16, 2022.

Counselor Name *

First Name Last Name

Date of Birth *

Date

Sex: *

Male Female

E-mail *

example@example.com

Home Church, City, & Denomination *

Church Phone Number *

Are you a member? *

Yes No

Pastor's Name (We will reach out to your pastor for a letter of recommendation.) *

Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Cell Phone *

Emergency Contact *

First Name Last Name

Emergency Contact Phone Number: *

Please enter a valid phone number.

Emergency Contact Email: *

example@example.com

Relation to Counselor: *

Personal Testimony:

Medical Release Agreement

The above-named Counselor acknowledges that he/she carries and is covered by his/her own medical insurance. Pine Summit and Camp staff are safety conscious and follow appropriate safety procedures, and in the event of injury or illness EVERY EFFORT WILL BE MADE TO CONTACT THE EMERGENCY CONTACT NAMED ABOVE. The undersigned authorizes Camp staff to administer first aid, and/or consent to medical treatment where, in the judgment of Camp staff, this becomes necessary.

The health information on this form will only be shared, as needed, with Pine Summit group leaders, Camp staff, and medical professionals to safeguard and support the Counselor. This information will not be publicly disseminated or released to any outside organization.

Counselor’s Health History

Describe any relevant health issues:

List any allergies:

List any other conditions, activity restrictions, or special-care needs:

Code of Conduct

It is expected that all Counselors will conduct themselves in a Christian manner at all times during the Camp. Where, in the judgment of Camp staff, and after being warned against such, a Counselor defiantly continues in inappropriate conduct or language, presents significant behavioral problems, or engages in particularly egregious actions that could endanger himself or others, the Counselor may be dismissed from Camp. In such cases, no portion of the Camp fees will be refunded.

Release of Liability

Execution of this Agreement represents an assumption of risk by the Counselor and a waiver of liability for any injuries incurred by the Counselor from participation in activities at the Camp, and explicit indemnification for liabilities of every kind against Grace Presbyterian Church, Pine Summit, Camp staff, or any other person or organization connected with the supervision or operation of the Camp.

Grace Presbyterian Church retains the right and permission to publish photographs taken during Youth Camp for use in electronic or print publications.

The undersigned Counselor hereby acknowledges and represents that he/she is at least 18 years of age, has read this entire document, understands its terms and provisions, recognizes that this is a binding agreement, and is signing electronically below voluntarily and in full cognizance of these facts.

Signature *

Clear

After hitting the "Register" button below, you will be taken to a payment page. Please select the Youth Camp payment option for Counselors.

Southwest Reformed Youth Camp - June 13-16, 2022