Tar Hollow Staff Application

Confidential Medical Form
No one will be permitted to attend Tar Hollow without this form on file. Medical history information will be kept confidental by the camp medical, administrative, and kitchen staff. It will only be shared if necessary to provide adequate care for you. This information will be properly destroyed at the conclusion of camp.
Name*

First NameLast Name
Phone Number*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth*

MonthDayYear
In detail, list all prescription and non-prescritpon medicines taken. Include the NAME, DOSAGE, and SCHEDULED times for each.*
List all sensitivity and allergic reactions to medicine, food, insect, seasonal, and environmental situations. Include effects when exposed.*
NEW MEDICATION PACKAGING POLICY
Signature (I have read, understand, and agree to comply with the new medication packaging policy.)*
Date*

MonthDayYear
Do you have, or have you had:
Recent Serious Injury*
Recent Surgery*
Epi-pen*
Chronic Medical Condtion*
Other Health Concerns*
If you selected YES for any of the above questions, please describe in detail.
Date of last tetanus shot*

MonthDayYear
IF YOU HAVE A FOOD ALLERGY OR SPECIFIC DIETARY NEEDS (i.e. Vegan, Vegetarian, Gluten, Dairy, Nut, etc...), please read the following:

Tar Hollow will provide a detailed list of meals for the week upon request. It is the STAFF MEMBER's RESPONSIBILITY TO PROVIDE appropriate food substitutions for items that cannot be consumed. Label the items with your full name, which item it is replacing, and directions for preparation. Identified kitchen staff will prepare this for you at the correct time. Please go to the serving line to pick up your specific food at the identified meal.
I will need a detailed list of meals due to dietary restrictions.*
EMERGENCY CONTACT INFORMATION
Name*

First NameLast Name
Relationship to Staff Member*
Cell Phone Number*
Alternate Phone Number*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
MEDICAL INSURANCE INFORMATION
Upload a photo of the FRONT of your insurance card.
Name of Company*
Policy Number*
Company Phone Number*
Policy Holder Name*

First NameLast Name
Policy Holder Phone Number*
Policy Holder Address*

Street Address

Street Address Line 2

CityState

Zip Code
PERMISSION TO TREAT

I understand that the camp nurse or other qualified medical personnel will administer any necessary first-aid and/or other over-the-counter medicines for any minor injuries or illnesses. If a serious injury or illness should occur, emergency medical care may be administered by qualified Camp Personnel and that, if any further medical treatment is deemed necessary, it will be obtained at the nearest Healthcare Provider/Facility as soon as possible. I further understand that, in the event of a serious injury or illness, every possible effort will be made to contact my primary contact person at the earliest possible time. However, if time does not permit or circumstances do not allow for this contact, I hereby give my permission to qualified camp personnel to provide emergency treatment and for the Healthcare Provider/Facility to provide emergency treatment or surgery as deemed necessary. This permission is in effect from the time I enter the Campground area and become subject to Camp jurisdiction until the time I leave the Campground area and I am no longer subject to the Camp jurisdiction.
Date*

MonthDayYear
Signature*

Break
Federal Background Check and Church Reference

Feel free to email tarhollowchurchcamp@gmail.com if you are unsure of when you last completed this.
- Federal Background Checks are required every 5 years.
- If you happen to miss camp for a year, a new background check would need to be completed.
- The attached SERVENT LEADER APPLICATION form needs to be completed and mailed to Tar Hollow c/o Sidney First Methodist Church along with a copy of your DRIVERS LICENSE and payment of $15 for processing your Federal Background Check.
- Pastoral References are completed on the same cycle as Federal Background Checks.
- Have the attached 2026 PASTORAL REFERENCE form completed by a staff member at the church in which you are currently involved.
- This needs to be completed and submitted to Tar Hollow by June 10, 2026.
- This can be emailed to the address on the form or mailed to Tar Hollow c/o Sidney First Methodist Church.

Camp Cost Form
It is suggested that each staff member cover the cost of their meals while at camp (approx $50.00)

Additional Camp Swag

Our camp swag is avaliable in our camp online store! Please visit tarhollowchurchcamp.org for link to order!!! Camp Attire will be delivered at camp!
Would you like a Camp Photo?*
PAYMENT OPTIONS:

Mail Payment: Tar Hollow 230 Poplar St Sidney Ohio 45365

OR

VENMO: @Tar-Hollow

- PLEASE MAKE SURE YOU PUT YOUR NAME ON THE VENMO TRANSACTION!!
Name*

First NameLast Name
Phone Number*
Donation of Meal Amount :*
Should be Empty:

Tar Hollow Staff Application

Personal Reference

Confidential Medical Form

Federal Background Check and Church Reference

Camp Cost Form