MK Camp Jr. Counselor Registration Form

Camper's Name

First NameLast Name

Birth Date

MonthDayYear

Age as of Aug 1

Grade

Gender

City where you live (and country if not Honduras)

Jr. Counselor's Email

example@example.com

T-Shirt Size

Have you attended MK Camp Honduras before?

I prefer to be a counselor for roughly ages:

Other areas I'm interested in serving are:

Parent/Guardian Information

Name

First NameLast Name

Relationship

Phone Number

Area CodePhone Number

E-mail

example@example.com

Emergency Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Area CodePhone Number

Medical Information

Do you have any disability or medical illness? If yes, please describe.

Do you have any blood borne illnesses? If yes, please describe.

Do you have any food allergies? If yes, please describe in detail including severity of reaction. We will ask you to work with our chef to insure they have safe options all week.

Do you have any dietary restrictions that are not allergy related? Please describe.

Do you have any other allergies? If yes, please describe in detail including severity of reaction. This includes but is not limited to allergies to medicines, bee stings, and cosmetic products.

Are you currently taking any medication? If yes, please list medication and dosage.

Are you prescribed an inhaler? If yes, PLEASE BRING THE INHALER and explain any instructions.

Any other comments, questions, or concerns?

Informed Consent and Acknowledgement (Please have a parent or guardian sign)

I hereby give my approval for my child’s participation in any and all activities prepared by MK Camp Honduras. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless MK Camp Honduras 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 MK Camp Honduras, including all staff, all participants, owners and lessors of premises used to conduct the event. As parent/guardian, I understand that my child’s participation will
include strenuous aerobic exercises, as well as a great deal of excitement in connection with the camp program. I acknowledge that injuries may occur as a result of participation in this camp, and I accept that consequence. I hereby authorize the MK Camp medical staff or other appropriate personnel to provide first aid, emergency medical care, or if necessary, admission to an accredited hospital, when such care is necessary for the treatment of any injuries my child may sustain while participating in any activity associated with MK Camp.

As the parent/guardian of the child named above, I give consent for my child to be photographed and/or filmed while attending MK Camp Honduras. This authorization covers the use of these photographs and videos to be reproduced and used in promotional material for MK Campin the future.

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.

Date

Parent Signature

Commitment

I understand that by choosing to be a Jr. Counselor I am accepting responsibility not only for my own actions but for the care and well being of younger campers. I take that responsibility seriously and I am willing to fulfill the job to the best of my ability. I understand that I may be asked to do things that might not be my preference but I will do them to the extent of my capability with a cheerful and God centered attitude. I commit to read the MK Camp Handbook and be responsible for carrying out the content within. I am excited about helping make MK Camp a place where we all grow closer to God and each other!

Jr. Counselor Signature

MK Camp Jr. Counselor Registration

Camper Information