Staff and Counselor Application and Waiver 2023

Full Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Primary Phone Number *

Area Code Phone Number

E-mail

Birth Date *

Month Day Year

Have you ever been convicted of a crime other than a minor traffic violation? *

Yes No

If yes please indicate thae date and nature of the offense.

Are you currently under investigation, or have you ever been recorded by the Department of Social Services (or any equlvalent department/agency) for child abuse and/or neglect or any criminal activity involving a minor? *

Yes No

If yes please indicate thae date and nature of the offense.

Please list any dietary needs or requirements. This information will be shared with the Kitchen Staff.

Please list any medical issues or health concerns that the Camp Medical Staff should be aware of or that requires special attention.

Emergency Contact Name *

First Name Last Name

Emergency Contact Phone Number *

Area Code Phone Number

Release and Waiver of Liability and Indemnity Agreement

Whereas the undersigned parent, legal guardian, next of kin, on behalf of himself or herself, his or her personal representatives, heirs, and next of kin, camper, child ( herein referred to as "Applicant") or participant acknowledges that even though every effort is made to provide a safe accident-free environment, incidents may occur. In consideration for the camper listed above being accepted by the 2000 Strong Youth for Christ Staff for participation in this camp, I (Applicant) being 21 years of age or older, do for myself, ourselves, Applicant, (and for and on behalf of my child-participant, if said child is not 21 years of age or older) hereby release, forever discharge and agree to hold harmless the aforementioned 2000 Strong Youth for Christ Staff and the Directors, Officers, Volunteers, Servants, and Agents (collectivlely the "Released Parties") Applicant hereby releases, waives and covenants not to sue for, and Applicant shall indemnify, defend and hold harmless 2000 Strong Youth for Christ and Released Parties thereof from and against any economic or non-economic losses, any and all liability, damages, suits, actions, claims and attorney's fees, costs, expenses, or demands. of every kind and nature whatsoever, whether for bodily injury, porperty damage, death, or loss otherwise, whether caused in whole or in part by the negligence, gross negligence or strict liablity of the released parties or otherwise to the fullest extent permitted by law arising from or alleged to have arisin from Applicant's presence, observation, use or participation at or in the 2000 Strong Adventure Camp , and or the presence, observation, use or particitpation of any family member, dependenat or guest, including any minors, accompanying applicant at or in the camp. Applicant voluntarily agreess to indemnify, hold harmless, assume full responsibility for and defend the Released Parties from any risk of bodily injury, death, or property damage while Applicant, Applicant's Family Member , Dependent, or Guest including any Minor's accompanying Applicant are present in, observing, using or participating in the camp or arising out of or in any way connected to Applicants, Applicants Family Member, Dependent, or Guest, including claims or demands for personal injury, sickness or death as well as property damage and expenses of any nature whatsoever whether caused in whole or in part by the negligence, gross negligence or strict liability of the Released Parties or otherwise to the fullest extend permitted by law which may be incurred by the undersigned, Applicant, the child-participant that occur while said Child, Applicant is participating in the above described camp.Applicant assumes full responsibility for any items lost or stolen while Applicant is present in, observing, using or participatind in the 2000 Strong for Christ Adventure Camp.Applicant also states that Applicant is not under the influence of any chemical substance, including but not limited to, medications, illegal drugs, and/or alcohol, at the time of execution of this Release and Waiver of Liability and Indemnity agreement, and will not be under the infuence of any chemical substance, including but not limited to medications, illegal drugs, and/or alcohol, during the ovservation, use,or participation in or at the 2000 Strong Adventure Camp.In addition, authorization and permission is hereby given to said organization to furnish any necessary transportation, food and lodging for this participant. The undersigned further agrees to hold harmless and indemnify said organization, its directors, employees and agents for any liability sustained by said organization as the result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto.Furthermore, in consideration of any child under the age of eight years old must be accompanied by a parent or legal guardian at any and all times including, but not limited to, sleeping in the same cabin as the parent or legal guardian while at 2000 Strong Adventure Camp. Applicant further expressly agrees that this Release and Waiver of Liability and Indemnity Agreement cannot be altered in any way, and is intended to be as broad and inclusive as permitted by Texas Law, and that if any portion of the Release and Waiver of Liability and Indemnity Agreement is held invalid, Applicant agrees that the balance shall, notwithstading, continue in full legal force and effect.Applicant fully understands that Applicant's entrance, observance, use, or participaton of, on, in the 2000 Strong Adventure Camp is entirely voluntary, Applicant has read and understood this Release and Waiver of Liability and Indemnity Agreement, has voluntarily signed this Release and Waiver of Liability and Indemnity Agreement, and arees that no oral representation, statement, or inducement apart from this written agreement have been made to Applicant.

Applicant's Statement

I hereby attest and certify that I have never been convicted of nor pled guilty to child abuse, endangering children, gross sexual imposition, voyeurism, public indecency, and offense of violence, or any existing or former offense of any municipal corporation, any state, United States, or any other nation that is substantially equivalent to any of the above offenses. (If you have been convicted of or pled quilty to any of the above offenses and wish to explain the circumstances therof, please do so on a separate sheet.) I further certify that I have never been discharged from employment or a volunteer position because of any activity covered by the foregoing. I hereby authorize 2000 Strong for Christ to conduct a check of my police criminal records and agree that I will fully coorperate in providing all information and signing all documents necessary to conduct such a check. I hereby attest and certify that the above information provided by me is true and correct to the best of my knowledge. I understand that misrepresentations or omissions may disqaulify my application or result in my immediate dismissal if I am already serving in a children - and youth - related position.

Please check to aknowledge that you have read and agree to the above release and waiver. By checking this box you are providing an electronic signature. An electronic signature will be equally as binding as an original manual paper signature. *

I AGREE

Payment Choice 1 - Use payment choice 1 options below if you are paying by credit card at this time, after checking the desired fields below and hit submit you will be taken to paypal to complete payment.

Payment Choice 2 - Use payment choice 2 options below if you do not wish to pay now or wish to pay by check please fill out the fields in Payment Choice 2 and click submit at the bottom of the page. You will be taken to the paypal page once there just exit page.

Payment Choice 1

My Products Please scroll to bottom of page enter message as shown and click submit.

Adventure Camp Fee $ 275.00

Staff and Counselor fee.

Tshirt $ 20.00

Camp Tshirt with year and theme.

Quantity Size

Total $ 0.00

Payment Choice 2

I will mail my check to 2000 Strong for Christ P.O. Box 117024 Carrollton, TX 75011.

Yes

Enter the message as it's shown *

Applicant Information

Emergency Contact Information