Volunteer Application Please complete the form below Applicant Name * First Name Last Name Applicant Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Applicant Date of Birth * MM DD YYYY Phone * (###) ### #### Camp(s) in which you desire to work * Teen Camp (Grade 9-12) Youth Camp (Grade 3-8) Jobs that interest you: Senior Counselor Certified Life Guard Junior Counselor Kitchen Help Camp Nurse Job Info School Attending Last year of school completed Church Affiliation/Congregation * TShirt Size * Small Medium Large XL 2XL 3XL Background Information Do you use alcohol? * Yes No Do you smoke? * Yes No How is your general health? * Describe any health problems: * Explain your experience working at a camp: * Explain your interest in working at Camp Shiloh: * Have you ever been convicted of any crime relating in any manner to children and/or your conduct with them? * Yes No If yes, please explain: Have you ever been convicted of any crime including but not limited to those listed below and/or any crime similar in any manner to those listed below? * -Indecent assault and battery on a mentally challenged person -Indecent assault and battery on a person who has obtained the age of fourteen -Rape -Rape of a child under sixteen with force -Assault with intent to commit rape -Kidnapping of a child under sixteen with intent to commit rape -Distribution and trafficking of narcotics or other controlled substances -Intent to commit any of the above crimes Yes No If yes, please explain: Have you ever been adjudged liable for civil penalties or damages involving sexual or physical abuse of children? * Yes No If yes, please explain: Are you now or have you ever been subject to any court order involving sexual or physical abuse of a minor, including, but not limited to a domestic order or protection? * Yes No If yes, please explain: Have your parental rights ever been terminated for reasons involving sexual or physical abuse of children? * Yes No If yes, please explain: Applicant Medical Information List all known medical conditions (or type NONE): * Medications with instructions for use (or type NONE): * Are ALL immunizations current? * Yes No Date of last tetanus shot: * Primary Care Physician * First Name Last Name Physician Phone Number * (###) ### #### Dentist Name * First Name Last Name Dentist Phone Number * (###) ### #### Insurance Company * Policy Holder Name * First Name Last Name Policy Number * Group Number * AGREEMENT TO PARTICIPATE: ASSUMPTION OF RISK AND RELEASE OF LIABILITY WHEREAS, THE UNDERSIGNED (the PARTICIPANT) wishes to be accepted for participation in all activities conducted by Camp Shiloh Lutheran Retreat Center. In consideration of, and for the right to participate in such activity by Camp Shiloh Lutheran Retreat Center, it’s Directors, Officers, Trustees, Employees, Agents, and/or Associate, I/we have and do hereby assume all of the risks and any other ordinary risk incidental to the nature of the activity. Further I/we will hold them harmless from any hospital bills, and doctor bills, or other wise, which the participant now has or which may arise from or in connection with participation in any other activities arranged for me by Camp Shiloh Lutheran Retreat Center, it’s Directors, Officers, Trustees, Employees, Agents, and/or Associates, and their heirs, executors, and administrators, successors and assigns and for all members of my family, including any minors accompanying me. I/we fully understand that my physical activity involves risk of injury. I/we also understand that my participation in any activity is entirely VOLUNTARY. I/we enter into this activity and take full responsibility for the decision to participate or not to participate and agree to follow all safety instructions. MEDICAL AND MEDICATION AUTHORIZATION AND RELEASE I/we hereby authorize the camp nurse or camp director to administer the medication listed on this form. If a medical emergency should arise while the above listed applicant is in attendance at Camp Shiloh, I/we hereby authorize the camp nurse or camp director to provide care to the camper and/or transport the camper to a medical facility. I/we further authorize the health care provider of the medical facility to administer necessary medical and /or surgical care upon arrival at the medical facility. I/we understand that camp officials will make a conscientious effort to locate the emergency contact listed on this document before any action will be taken. If it is not possible to locate the emergency contact listed, I/we will accept the expense of emergency medical and/or surgical treatment. If the applicant is a minor, I/we give my authority and consent for Camp Shiloh or camp nurse to treat my child for a headache, fever, or upset stomach with the appropriate non-prescription medication excluding Aspirin and Pepto-Bismol. By providing this digital signature, I am affirming that all of the information provided on this form is accurate and complete. Emergency Contact Information Emergency Contact Name * First Name Last Name Relation to Applicant * Emergency Contact Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Cell Phone * (###) ### #### Additional Contact Info Approval for minor Applicant to be picked up by the following individuals other than Parent(s)/Guardian(s) Your child will be released prior to lunch following the Closing Program. Only the enrolling parent, parents, guardian, or guardians and the individuals they identify on this form will be allowed to pick up a child from Camp Shiloh Lutheran Retreat Center. Please list all individuals to whom Camp Shiloh Lutheran Retreat Center’s staff is authorized to release your child. Safe to Release to: Please enter Name/Relation to Camper/Phone Number of anyone who is authorized to pick up your camper. Signature of Applicant (or Parent/Guardian if applicant is under 18 years of age) By typing your name in this field, you are agreeing that everything listed in this form is true and accurate to the best of your knowledge. First Name Last Name Thank you!
