Clone of 2025 Counselor Registration Form

Reference

Please provide a reference from your Home/Sponsoring church.
Reference Name*

First NameLast Name
Title*
Reference's Phone Number*
Please enter a valid phone number.
Medical Release:
In case of emergency, I understand that every effort will be made to contact the Emergency Contact previously named. In the event he/she cannot be reached, I hereby give permission to the physician selected by the camp nurse or director to hospitalize and secure proper treatment (including surgery).
Signature
Do you have any allergies (food or environmental) that we should be aware of?*

NOYES
If YES, please explain*
Do you have any special dietary needs?*

NOYES
If YES, please explain:*

Media Release
Individual and group photos taken at camp may be used in any or all forms of media for advertising. The names of the campers/sponsors will not be used if photos are placed on our website or other social media websites. By signing below I give permission for Camp Christian to take /use photos of myself or child for advertising and media purposes.
Signature

Child Abuse Statement:
I hereby state that I have never been convicted of any felony child abuse, or unlawful sexual offense.
Signature
Background Check:
I have a current (performed in the past 5 years) background check report on file with my home church.I do NOT have a current background check report but will complete the consent form (provided by camp) 5 days prior to camp.
Perjury Statement:

Any staff member or volunteer who knowingly or willfully makes a false statement of any material fact in the registration process is guilty of perjury in the second degree and upon conviction thereof, shall be punished accordingly.
Printed Name*

First NameLast Name
Signature: Signature

2026 Counselor Registration Form