2024 PB & J Adult Staff Application

PB and J Adult Staff Application

Read the announcement sheet below in full before proceeding. This has all requirements listed for the application to be complete.
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
Adult T-Shirt Size

SmallMediumLargeXLargeXXLarge
Medical Permission Form
Name

First NameLast Name
Phone Number

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Emergency Contact

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

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.
Date

MonthDayYear
Date
Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Website Updates

We are now going to put your bio and head shot on the website for parents to get to know you a bit better. This should really make a good connection with campers.
Short Bio Describing you for the website
Upload a Head shot to include with your bio

Browse Files

Cancelof

PB and J Adult Staff Application

Medical Permission Form

Waiver of Claim/Media and Medical Release

Website Updates

Background Check and ID upload