Address  

City  State  Zip

Home Phone  Work Phone  Cell Phone

Email Address  Birthday

Occupation    Drivers Licence Number  State of Issue

I am interested in serving in the Regional Camping Program...
At:    Gwinwood    Zephyr
As:    Counselor    Co-Director
With: Kids    Junior    Chi Rho    CYF

Medical Information Updates
Please complete this section if any medical conditions have changed, medications have been added or taken away from your routine, or Insurance Info has changed.

Allergies: Please check all that apply
Bee Sting   Seasonal/Pollen   Mildew   Poison Ivy   Aspirin   Penicillin   Sulfa   PoisonOak

Other Allergies:

Food Allergies:

General Health History: Please check all that apply

Others:

Please explain any of the above which are checked; note especially recent illnesses, procedures, surgeries:

Medications: Include Over-The-Counter drugs as well.
 
Medication 1.      Dose      Time

Medication 2.      Dose      Time

Medication 3.      Dose      Time

Medication 4.      Dose      Time

Other Emergency Care Information

Insurance Provider, Policy and/or Group Number:

Physician and Physician Phone Number:

Are Immunizations up to date (including Tetanus)? Yes     No

Emergency Contacts
Please complete this section if you are a Counselor in Training or if your Emergency Contacts have changed.

Contact 1
Name:      Relationship to you:

Home Phone:   Cell Phone:   Other Phone:

Contact 2
Name:      Relationship to you:

Home Phone:   Cell Phone:   Other Phone:

Your Committment and Background Check Authorization
I desire to serve as a camp counselor for the NWRCC during the current year’s summer camp season.  I understand that the references I have listed may be contacted to confirm my character and abilities as appropriate for leadership in the camp and conference program.  I promise to cooperate with other counselors, directors and staff and to uphold all standards set forth by the Region and the Directors.  With God’s help, I will seek in every way to provide an experience on the highest Christian level for all who attend the camp which I serve.  I will participate in all training opportunities planned for the event and at all times will conduct myself as the Christian example I am called to be.  I understand that the Camp and Conference Directors will be allowed to review this application for staff planning purposes.

Attention: The NWRCC is authorized to conduct criminal background checks on volunteers at its Camp and Conference programs.  All staff participating in the Regional youth events must agree to the request for Criminal History Information as per the Child/Adult Abuse Information Act, RCW 43.43.830 through 43.43.845

Please Select the "Agree" Button to acknowledge your committment and agreement to the use of your personal information to perform a background check.
Agree:

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