Summer 2025 Staff Registration

Summer 2024 Staff Registration

Aug 15th-19th, 2024 Address - 2858 180th St, Muscatine, Iowa
We are so excited to have you join us and help in Aug for our Youth Summer Camp.

Lion Of Judah

The camp will be Aug. 10th-15th of 2025. We will begin check-in at Spring Valley Bible Camp on Sunday at 2pm and will conclude camp on Friday at 11am.

We can't wait to meet all of our new friends at Midwest Messiah! Until then, if you have any questions, you are welcome to email us at MessiahMidwest@gmail.com.
Staffer Information
Staff Name*

First NameLast Name
Staff Email*

Confirmation EmailPlease retype your email to confirm.
Staff Phone Number*

Area CodePhone Number
Birth Date*

MonthDayYear
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
T-Shirt Size (Adult Sizes)*

SmallMediumLargeXL2XL3XL4XL
Areas of Help*

Kitchen StaffTeam Leader (Counselor)Worship TeamMediaSecurityNurse/MedicalOther
Congregation/ Church
Congregational Leader
Emergency Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Relationship*
Emergency Contact Phone Number*

Area CodePhone Number
RELEASE, WAIVER, AND AUTHORIZATION FOR MEDICAL TREATMENT
I understand the activities are not without some inherent risk of injury.

In consideration of my right to participate in this activity, I agree to release, waive, discharge, agree not to sue, and to hold harmless for any and all purposes Midwest Messiah and their officers, employees, agents, and volunteers. I release Midwest Messiah from any and all liabilities, claims, or injuries, including death, that may be sustained while participating in this activity, including swimming, including traveling to, from, and for the activity, or while on premises owned or controlled by Midwest Messiah, including injuries sustained as a result of the negligence of Midwest Messiah. I understand this release does not apply to injuries caused by intentional or grossly negligent conduct on the part of Midwest Messiah. I further agree to indemnify and hold harmless Midwest Messiah for any loss, liability, claim, or injury caused by me (my child) while participating in this activity, including traveling to, from, and for the activity, or while on premises owned, leased, rented, controlled, or operated by Midwest Messiah.

I also give my permission for me to receive any emergency medical treatment by a
healthcare professional, including emergency medical transportation, which may be required for injuries sustained by me.

I agree to indemnify and hold harmless Midwest Messiah for any costs incurred to treat me, even if a Midwest Messiah officer, employee, agent, or volunteer has signed hospital documentation promising to pay for the treatment.

Furthermore, I agree to follow all instructions and procedures in order to maintain a
maximum level of safety.
Participant's Name:*

First NameLast Name
Participant's Signature*

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Date*

MonthDayYear
Date
HEALTH STATEMENT
Event: Midwest Messiah Youth Summer Camp Aug 15-19, 2024

The proposed activity provided by Midwest Messiah requires participation in physical exercises which are, by their nature, physically demanding. Many of the activities will challenge you and
cause surges in blood pressure and pulse rates. It is imperative that you are free of any heart
related or other diseases. Therefore, all participants must be free of medical or physical
conditions which might create undue risks to themselves or any others who depend on them. If there is any doubt about your ability to safely participate in this experience, you should have a physical examination.
Health History

(Select the appropriate answer and explain any YES responses on the space provided below.)
Have you had or do you currently have any heart problems:*

YesNo
Does the Staffer have any allergies, chronic illnesses, or medical conditions? If yes, please answer the next question.

YesNo
List allergies, chronic illnesses, or medical conditions.*

YesNo
Does the Staffer use an inhaler or carry an epipen? If yes, please answer the next question*

YesNo
Please list inhalers used or needs of your epipen
Do you frequently suffer from pains in your chest:*

YesNo
Do you often feel faint or have spells of severe dizziness:*

YesNo
Has a doctor ever told you that you have high blood pressure:*

YesNo
Are you a smoker:*

YesNo
Do you have arthritis, joint, or back problems :*

YesNo
Have you had any operations or serious injuries:*

YesNo
Do you have any chronic recurring illness or communicable diseases:*

YesNo
Are there any activities to be limited by a physician's advice:*

YesNo
Are you allergic to any medicines, insects, or pollens:*

YesNo
Do you have Epilepsy:*

YesNo
Do you have Diabetes:*

YesNo
Do you have any prescribed meal plan or dietary restrictions other than Biblically clean:*

YesNo
Please explain any yes answers.
Insurance Information
Do you carry family medical/hospital insurance?*

YesNo
Carrier:*
Policy Number*
Policy Holder*
Carrier Phone Number*
Representation
This health history is correct so far as I know. I believe that my health is satisfactory to
participate in the Midwest Messiah 2024 Summer Camp activities. I also understand and agree to abide by any restrictions placed on my activities.
Staff Name*

First NameLast Name
Staff Signiture*

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Date*

MonthDayYear
Date
Spiritual Questions
How did you come to walk in your faith with Yahweh/God? (Testimony)
Why do you believe you should receive eternal life?
In your words, what is the Gospel?
Spiritual Refrence
Reference Phone Number
Reference Email
At Midwest Messiah events, we require background checks, to protect the campers and staff. Are you ok with MWM completing a background check on you?

YesNo
Should be Empty:

Summer 2024 Staff Registration

Staffer Information

Emergency Information

RELEASE, WAIVER, AND AUTHORIZATION FOR MEDICAL TREATMENT

HEALTH STATEMENT

Health History

Insurance Information

Representation

Spiritual Questions