Adult Counselor Registration and Medical Release 2022

Form 1 of 3
WAPAC ADULT COUNSELOR REGISTRATION AND MEDICAL RELEASE

WASHINGTON PACIFIC DISTRICT CHURCH OF THE NAZARENE
You are applying for a Camp Counselor position for the WAPAC District Kids Camp. Please be careful to fill in all required fields before hitting submit. This will expedite your registration process and help to reduce errors in submission which may require you to start the form over. There are 4 steps to complete to be a WAPAC Kids Camp Counselor: 1) Apply by completing this online registration form. 2) Attend one of our online counselor training sessions. The session dates are listed in this form. 3) A complete and approved background check (You will be sent to a Release of Records form upon submitting the registration form.) 4) The WAPAC Kids Camp Registrar will contact you upon completion of the entire 4 step process.
There are a total of 3 forms to fill out online. You will automatically be directed to each form when you push submit. Please fill out all forms listed below for complete registration. - WAPAC Adult Counselor Registration and Medical Release - WAPAC Adult Release of Records - Crista Camp Release and Waiver
WAPAC Adult Counselor Registration and Medical Release July 11th-15th
Full Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
T - Shirt Size *
Gender *

Male Female
Cell Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Church you are attending with
E-mail *

Confirmation Email
#1 Emergency Contacts Name *

First Name Last Name
Emergency contact mobile phone *

Area Code Phone Number
#2 Emergency Contacts Name *

First Name Last Name
Emergency contact mobile phone *

Area Code Phone Number
CAMP GUIDELINES

We expect all counselors to conform to these rules of conduct: No possession or use of alcohol, drugs, or tobacco. No fighting, weapons, fireworks, lighters, or explosives. No offensive or immodest clothing. Cell phones for campers are not allowed, however, counselors may utilize their cell phones for the sake of communication with camp leadership and personal use. Sleeping quarters will be respected with female leaders in girls cabins only and male leaders in boys cabins only. Participation with the group is expected. Respect of property. Respect of one another, campers, Christa Camp staff, and district camp leadership. Respect and comply with the event schedule of camp. Compliance with all child safety measures from the counselor training sessions, directives from district camp leadership and directives from Christa Camp staff. Adults who fail to comply with these expectations may be sent home at their expense.

I, the participant, have read the rules of conduct, the above evaluation of my health, and permission to participate in camp activities. I agree to abide by the stated personal limitations and code of conduct.
Full Name *

First Name Last Name
Check here for your Electronic signature acknowledging the rules of conduct above *

I acknowledge the above rules of conduct and my check here as my electronic signature
Camp Counselor Training

We strive to provide a safe environment for kids at WAPAC Kids Camp. Each counselor is required to attend our mandatory 60 minute counseling training (a video training). This training is necessary to fully participate as a camp counselor at WAPAC Kids Camp this summer. Thank you for your partnership in creating the best camp experience for kids!
What is covered at the Counselor Training?

Topics covered include: Make a Difference, Defining Child Sexual Abuse, Behavioral Characteristics of Both Victims and Child Molesters, and Recognizing Trauma.
Medical Release and Information
Medical Insurance Company *
Policy #
Policy Holder Information / Name
If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, disability, or condition to which you are subject and of which the staff should be aware, and what, if any action of protection is required on account thereof.
Do you suffer from, or has ever experienced, or is being treated currently for any of the following *

asthma epilepsy / seizure frequently upset stomack physical handicap heart trouble diabetes None Known
Do you have allergies to *

pollens medications food insect bites None Known
Date of last tetanus shot: m/d/year *
Please list and explain any major illnesses you have experienced during the last year: If none answer N/A:
Any medications you bring to camp are required to be in its original container. Medications are not allowed in cabins and are to be kept with the camp nurse.
Please check one *

This person takes medications as follows This person takes no additional medications
Med #1
Reason for taking
Specifc times taken each day
Dosage
Med #2
Reason for taking
Specifc times taken each day
Dosage
Med #3
Reason for taking
Specifc times taken each day
Dosage
Dietary restrictions please check ALL that apply

Does NOT eat red meat Does NOT eat pork Does NOT eat eggs Does NOT eat seafood Does NOT eat dairy products Does NOT eat poultry
Others not listed above (describe)
Explain any dietary restrictions (e.g.,what cannot be eaten, what adaptations or limitations are necessary).
Ministry Experience
Have you received Christ as your savior? *

Yes No
Have you ever led anyone to Christ? *

Yes No
Are you comfortable leading someone to Christ? *

Yes No
How long have you been serving children or youth? *
Personal References
Please provide two personal references. No relatives please. Please have one reference be a pastor or board member.
Reference #1
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
Reference #2
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
Applicant Statement: The information contained in this application is correct to the best of my knowledge. I authorize any references listed in this application to give you any information they may have regarding my character and fitness for children’s ministry. I release all such references from liability for any damage that may result from furnishing such evaluations to you and I waive any right that I have to inspect the references provided upon my behalf. Should my application be accepted, I agree to be bound by the constitution, by-laws and policies of the Washington Pacific District Church of the Nazarene and to refrain from unscriptural conduct.
Electronic Signature *

checking this box signifies my acknowledgement of the above information as well as signifies my electronic signature here for the above listed name
Date *
This consent form gives permission to seek whatever medical attention is deemed necessary, and releases Washington Pacific District Church of the Nazarene and its representatives of any liability against personal losses of named person. I understand that there are inherent risks involved in any ministry or athletic event, and I hereby release the Washington Pacific District Church of the Nazarene, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my involvement. In the event that I am injured and require the attention of a doctor, I consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Washington Pacific District Church of the Nazarene, I agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I affirm that the health insurance information provided above is accurate at this date and will, to the best of my knowledge, still be in force for the person named above.
Electronic Signature *

checking this box signifies my acknowledgement of the above information as well as signifies my electronic signature here for the above listed name
Date *

My Products

Counselor Registration for one camp $ 330.00

Enter coupon

Payment Method

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

You will automatically be directed to the WAPAC Adult Release of Records when you push submit. You will need to fill out the next two forms to be fully registered for camp.
Should be Empty:

Camp Counselor Training

What is covered at the Counselor Training?

Medical Release and Information

Ministry Experience

Personal References