Emmaus Volunteer Leader Registration Form

Volunteer Leader Registration Form

Please complete this form to register as a volunteer leader for Emmaus Summer Camp, provide required information, and submit your registration fee.
Full Name*

First NameLast Name
Preferred Name
MaleFemaleNon-binaryPrefer not to say
Date of Birth

MonthDayYear
Date
Email Address*
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number*
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship
Why do you want to serve at Emmaus Summer Camp?
YesNo
If yes, please describe your experience
YesNo
If yes, what role?
Preferred Role
Do you have any medical conditions we should know about?
Do you have any dietary restrictions or allergies?
Are you currently taking medications?
T-Shirt Size
YesNo
Arrival Date

MonthDayYear
Date
Departure Date

MonthDayYear
Date
Personal careWheelchair mobilityFeeding assistanceBehavioral support
Strong swimmerBasic swimmerNon-swimmer
Have you ever been convicted of a crime? If yes, please explain.
Yes
YesNo
Do you have any medical conditions we should be aware of? If yes, please specify.
Do you have any dietary restrictions? If yes, please specify.
Are you currently taking any medications? If yes, please list them.

Volunteer Leader Attendee Fee*

Volunteer Leader Attendee Fee

Registration fee for volunteer leader

$250.00

Total

$0.00