Peer Mentor Application 2025

Camp T.A.L.K. Peer Mentor Application

Peer Mentors must be middle school age - 18 years old. Peer Mentors act as student buddies for campers and serve as a positive role model. Peer Mentors must be leaders in their school / community. One peer mentor will be selected per group.
Peer Mentor's Name*

First NameLast Name
Birth Date

MonthDayYear
Gender

MaleFemale
Age*
What school will the Peer Mentor will attend in the fall?
Peer Mentor's Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How did you hear about Camp T.A.L.K.?*
Teacher or Coach References

Peer Mentors must provide two teacher or coach references that we can contact who have seen you interact with other same age peers.
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Relationship to Peer Mentor Candidate
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Relationship to Peer Mentor Candidate

Parent/Guardian 1 Information
Name*

First NameLast Name
Cell Number*

Area CodePhone Number
Alternate Number*

Area CodePhone Number
E-mail*
Parent/Guardian 2 Information
Name

First NameLast Name
Cell Number

Area CodePhone Number
E-mail
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship
Phone Number*

Area CodePhone Number
Alt. Phone Number*

Area CodePhone Number

Which Weeks would you like for your Peer Mentor to attend? Peer Mentors must attend both days for the week that they select.*

Week 1 June 10th & 12thWeek 2 June 17th & 19thWeek 3 July 1st & 3rd
What size t-shirt does your Peer Mentor wear?*

Does the Peer Mentor have any allergies? If yes, please explain. *
Please list any diagnosis', health conditions, or physical limitations that we need to be aware of. *
Please provide the name & e-mail address or phone number of a teacher (or professional if homeschooled) that we may contact.*

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Camp T.A.L.K. / T.A.L.K. Services / Willow Ridge Church during the selected camp. In exchange for the acceptance of said child’s candidacy by Camp T.A.L.K. / Talk Services / Willow Ridge Church ., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Camp T.A.L.K. / Talk Services / Willow Ridge Church. and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against Camp T.A.L.K. / Talk Services / Willow Ridge Church. including all volunteers / group leaders and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all camp activities, including those of water and unknown territory. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature for Consent to Participate & Acknowledgement*

Clear
Photo Release

As Parent and/or Guardian of the named camper, I hereby give permission for Camp T.A.L.K. / TALK Services to use the Camper’s photograph, video footage, or interviews for promotional, advertising or media purposes. This includes the end of camp video. The undersigned hereby waives releases and forever discharges Camp T.A.L.K. / TALK Services, its officers, agents, employees or representatives, and all others, from any and all responsibilities, liabilities, or payment for the child / Camper’s participation. By Signing below, I agree to the terms in this photo release.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature for Photo Release*

Clear
Medical Release and Authorization

As Parent and/or Guardian of the named camper, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named camper. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to Camp T.A.L.K. / Talk Services / Willow Ridge Church and its affiliates including Directors, Volunteers, and Small Group Leaders to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature for Medical Release*

Clear
Peer Mentor's Physician & Insurance Information
Insurance Company*
Insurance Policy Number*
Primary Physician*
Physician's Phone Number*
What special skills, interests, or hobbies do you have that might interest our Camper's?
Why do you want to be a Peer Mentor at Camp T.A.L.K.?*
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Camp T.A.L.K. Peer Mentor Application

Teacher or Coach References