Youth Staff Registration 2023

PB and J Youth Staff Registration

Read the announcement sheet below in full before proceeding. This has all requirements listed for the application to be complete. Registration are due by Feb 11, 2023
Read COMPLETELY before moving onto complete application. If you are under 18, you will need your parents signature in this form.
Name*

First NameLast Name
Email Address*
example@example.com
Home phone number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell phone number*

Area CodePhone Number
*

MaleFemale
Date of Birth*
Highest Grade Completed by start of camp*
Adult T-Shirt Size*

SmallMediumLargeXLargeXXLarge
Medical Permission Form
Name*

First NameLast Name
Parent(s) Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Alternate Phone Number*

Area CodePhone Number
Emergency Contact (if parents cannot be reached)*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Physician Name

First NameLast Name
Physician Phone Number

Area CodePhone Number
Medical Payment Responsibility

InsuranceIndividual
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*

YesNo
Inhaler*

YesNo
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 (If 18 years old, applicant signature)*

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.
Parent Name (Skip if 18 years old or older)

First NameLast Name
Parent Signature and Claim/Media and Medical Release Form

Clear
Date

MonthDayYear
Date
Participant Name*

First NameLast Name
Participant Signature*

Clear
Date

MonthDayYear
Date
If you are over 18 years old or will be over 18 by the start date of camp -

Within 7 days of submitting your application, you will recieve an email with a request for a background check. Please follow the instructions and email all necessary paperwork in.

If you have been background checked previously (in the past 3 years with PB and J) please read and sign the following.

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
Parent Signature: Permission for youth staff participant to watch the movie "Breakfast Club" (rated R) at training event. (If over 18, skip)

Clear

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PB and J Youth Staff Registration

Medical Permission Form

Waiver of Claim/Media and Medical Release