Authorization and Release of Information / authorize any persons, congregations, or other organizations listed by me here to give to the offices of the Christian Church (Disciples of Christ) of Mid-America Region, any information they may have regarding my character, experience, and fitness for work with children or youth In consideration of the receipt and evaluation of this information given by me here, / hereby release offices of the Christian Church (Disciples of Christ) of Mid-America Region, its agents, successors, and administrators from any and all claims, actions, causes of action, demands, rights, damages, costs, loss of service, expenses and compensation whatsoever which may at any time result from the use of the information provided by the above referenced persons, congregations, or other organizations listed by me. / hereby waive any right / may have to inspect any information provided about me by any person, congregation, or other organization identified by me in this Camp Staff Application. / understand that the information provided by me in this form and any information provided by any person, congregation, or other organization listed by me in this Camp Staff Application may be shared with staff members in the Christian Church (Disciples of Christ) of the Mid-America. Should / become engaged in work with children or youth in church programs, / agree to be bound by the bylaws and policies of the Northeast & Ozark Areas of the Christian Church and to refrain from any unethical, abusive or exploitative conduct in the performance of my services in behalf of the church. / authorize submission of my name(s), address, social security number, and other personal identifiers for background check procedures used by toffices of the Christian Church (Disciples of Christ) of Mid-America Region for screening of paid and volunteer staff, including but not limited to searches of state and federal sex offender databases, criminal records, and child/elder abuse registries. Photography Release: / consent to be photographed while participating in camp or trip activities and for photos to be used during camp and afterward for educational and promotional activities.

The information supplied by me in the foregoing Returning Camp Staff Application is true and correct to the best of my knowledge. I have read the foregoing Authorization, and Release and fully understand it.