Spencer Lake Summer Camp Health Service Application

Weeks Available

Health Service Medical Qualifications

Educational/Special Training

Please upload a copy of current Medical License or Certificate

Name

First NameMiddle NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date Of Birth

Date

Social Security number

Drivers License Number

State Issued

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

In completing the Spencer Lake Summer Camp/Great Girls Escape/All Boys Camp application, IFirst Name* Last Name*ofCity* State*understand, represent, and agree that:

1. As part of the Spencer Lake Summer Camp/Great Girls Escape/All Boys Camp procedure for verifying the information provided by me on the Spencer Lake Summer Camp/Great Girls Escape/All Boys Camp application form or evaluating me as a staff member or volunteer leader, Spencer Lake Summer Camp/Great Girls Escape/All Boys Camp/Wisconsin/Northern Michigan District Assemblies of God (WNMD A/G) may contact persons, employers and/or organizations named by me in this form; conduct a national criminal background check; conduct a sex offender registry check; a social security trace or other appropriate background investigative reports which may include information gathered through personal interviews with third parties, family members, and persons, with whom I am acquainted. I consent to Spencer Lake Summer Camp/Great Girls Escape/All Boys Camp/WNMD A/G making such checks and understand that this may include information regarding my character, general reputation, and personal characteristics. I further agree to sign any and all documents, consents and/or agreements which may be necessary for Spencer Lake Summer Camp/Great Girls Escape/All Boys Camp/WNMD A/G and its authorized representatives and/or designees to complete the above. By signing this form, I authorize Spencer Lake Summer Camp/Great Girls Escape/All Boys Camp/WNMD A/G to request and obtain the information described above. Further, I release Spencer Lake Summer Camp/Great Girls Escape/All Boys Camp/WNMD A/G and its denominational agency, affiliates, related entities, agents, employees, and officers (collectively “Organization”) and all references from any claim or liability whatsoever arising out of such request or any information disclosed in response thereto, and I agree to hold the Organization and all references harmless and will not to bring any action or assert any claim against the Organization or any reference on account thereof.

2. I understand that my providing of false or misleading material information or my failure to state material facts either in this form or in any interview will result in the immediate rejection of my application as an Spencer Lake Summer Camp/Great Girls Escape/All Boys Camp staff member or volunteer team member or immediate dismissal if such false or misleading information is discovered after any Spencer Lake Summer Camp Health Services application is accepted by Spencer Lake Summer Camp/Great Girls Escape/All Boys Camp/WNMD A/G.

I have read and understand the above and affirm that the information I have provided on the application is true and correct.

Signature

Name

First NameLast Name

Date

Hour MinutesAM/PM Option

2026 Spencer Lake Summer Camp

Information Authorization And Release