Justified Retreat Adult Worker Application & Agreement

Justified Retreat Adult Worker Application & Agreement

Application for adults serving as workers at the Pine First Baptist Church youth retreat. This form is separate from the student application. Please complete all required acknowledgments and understand that medical information is not collected online; a separate paper medical, medication, and emergency authorization form must be completed and returned.
Adult Worker Information
Registration closes November 8, 2026.
Full Legal Name

First NameMiddle NameLast Name
Preferred Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
T-Shirt Size
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Pine First Baptist Church Membership
I verify that I am a member of Pine First Baptist Church.
Membership Received By
Background Check
I acknowledge that I have reviewed each required document, understand the early dismissal policy, and agree to abide by all stated policies and expectations.
Do not enter a Social Security number, background-check results, or other sensitive background-check information in this form.
I verify that I have completed the background check required for adult workers.
Code of Conduct Review
Review the Code of Conduct here: https://www.pinefbcyouth.com/resources/Pine-First-Baptist-Youth-Code-of-Conduct.pdf
Code of Conduct acknowledgment
Adult Worker Agreements and Acknowledgments
I acknowledge the general activity and risk statement
Are you proficient at swimming?
Are you proficient and comfortable supervising water-related activities?
Do you give us permission to put you in charge of water-related activities?
Current water comfort and ability

1

2

3

4

5

6

7

8

9

10

1 is Not comfortable, 10 is Very comfortable
Prior experience with boats, kayaks, canoes, or paddleboards

1

2

3

4

5

6

7

8

9

10

1 is No experience, 10 is Extensive experience
I certify the information provided is true and complete.
Certification and Signature
Certification
Printed Legal Name

First NameMiddle NameLast Name
Electronic Signature
Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty:

Justified Retreat Adult Worker Application & Agreement

Adult Worker Information

Pine First Baptist Church Membership

Background Check

Code of Conduct Review

Adult Worker Agreements and Acknowledgments

Certification and Signature