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Staff Registration
All volunteers that will be staffing one of the events is required to complete this form prior to the event. If there are any questions, please reach out to your Dean or the Board of Directors.
Staff Registration
Which event will you be staffing?
(Required)
Select All
Day Camp
Charlie Brown
Jr. Week
Jr. High Week
Sr. High
Family Day
Youth Retreats
Staff Member Name
(Required)
First
Last
Gender
(Required)
Male
Female
Staff Member Date of Birth
(Required)
MM slash DD slash YYYY
Email Address
(Required)
Staff Member Address
Street Address
Address Line 2
City
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New York
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North Dakota
Northern Mariana Islands
Ohio
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Texas
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U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Church You Attend
City/State
What area would you like to help out at?
Please check mark any areas you would like to learn more about or do while staffing.
Teaching
Recreation
Kitchen
Nursing
Music
Administrative
Projects
Select All
Medical Information
Allergies
(Required)
Eggs
Milk
Gluten
Peanuts
Shellfish
Soy
Tree Nuts
Other
None
Select All
If other, what?
If you selected an allergy above, please elaborate so that we may best serve in case of an emergency
Are you a Minor?
(Required)
Yes
No
Are your clearances up to date?
(Required)
Yes
No
Clearances
(Required)
Drop files here or
Select files
Max. file size: 512 MB.
Please upload your updated clearances.
Do we have a copy of your clearances?
(Required)
Yes
No
Please upload your Clearances
(Required)
Drop files here or
Select files
Max. file size: 512 MB.
Minor Details
Minor Medical Information
Health Record / Allergies
(Required)
ADHD
Anxiety
Asthma
Behavior Problems
Convulsions/Seizures
Depression
Diabetes
Sleepwalking
Heart Trouble
Other
None
Other/ Notes and Explanation
Please mark any medications that you give approval to be administered as needed through the week
(Required)
Tylenol
Ibuprofen
Antihistamine/Benadryl
Tums
Robitussin
Other
Select All
Please list any medications they are currently prescribed & dosage information for while they are a camper during their week of camp.
All meds are to be left with & dispersed by the Camp Nurse. All meds must be clearly marked with their name and in the original container from doctor or pharmacy.
Mother/Father/Legal Guardian Information
Mother/Legal Guardians Name
First
Last
Mother/Legal Guardians Phone Number
Father/Legal Guardians Name
First
Last
Father/Legal Guardians Phone Number
Health Insurance Information
Policy/Group Name
(Required)
ID #
(Required)
PCP Name
(Required)
PCP Phone #
(Required)
Heath Insurance Additional Information:
Emergency Contact
Emergency Contact
(Required)
First
Last
Emergency Contact Phone Number
(Required)
Relationship
(Required)
Minor Recreational Activity Release of Liability
(Required)
Express Waiver of Risk(s) Associated with Recreational Activities:
I, as parent or legal guardian of my child, hereby affirm and acknowledge that I fully understand the hazards and risks associated with the many outdoor and other recreational activities which my child may engage or participate in at Deep Valley Christian Service Camp. The inherent risks and hazards include but are not limited to:
1. Injuries sustained from any and all outdoor activities, such as running, jumping, hiking, swimming, biking, climbing, cooking, engaging in sporting events such as basketball, volleyball and more.
2. Injuries sustained from objects that are either natural or man-made, such as rocks, cliffs, trees and campfires, or from misjudging trails or other terrain that induces slipping, falling, colliding or otherwise.
3. Injuries and illnesses from swimming, diving, impacting the water and/or water entering bodily orifices.
4. Injuries from hypothermia, heat stroke, dehydration, etc. from exposure to the elements, such as rain, cold, excessive heat or the weather in general.
5. Injuries or illnesses sustained from either plants or animals, such as poison ivy, poison oak, poison sumac, aggressive or biting pets, service animals, wildlife, or exposure to any plants or animals present within the camp in general.
6. Accidents, injuries or illnesses occurring in remote locations where no immediate medical attention is available.
I UNDERSTAND THAT THE DESCRIPTION OF THESE RISKS IS IN NO WAY COMPLETE AND THAT ALL SUCH DANGERS, BOTH ANTICIPATED AND UNANTICIPATED, CAN LEAD TO ILLNESS, INJURY, PERMANENT DISABILITY, DROWNING OR DEATH.
I acknowledge that I have read and agree to the Waiver of Liability and Medical Consent statements
Recreational Activity Release of Liability
(Required)
Express Waiver of Risk(s) Associated with Recreational Activities:
I hereby affirm and acknowledge that I fully understand the hazards and risks associated with the many outdoor and other recreational activities which my I will either engage or participate in at Deep Valley Christian Service Camp. The inherent risks and hazards include but are not limited to:
1. Injuries sustained from any and all outdoor activities, such as running, jumping, hiking, swimming, biking, climbing, cooking, engaging in sporting events such as basketball, volleyball and more.
2. Injuries sustained from objects that are either natural or man-made, such as rocks, cliffs, trees and campfires, or from misjudging trails or other terrain that induces slipping, falling, colliding or otherwise.
3. Injuries and illnesses from swimming, diving, impacting the water and/or water entering bodily orifices.
4. Injuries from hypothermia, heat stroke, dehydration, etc. from exposure to the elements, such as rain, cold, excessive heat or the weather in general.
5. Injuries or illnesses sustained from either plants or animals, such as poison ivy, poison oak, poison sumac, aggressive or biting pets, service animals, wildlife, or exposure to any plants or animals present within the camp in general.
6. Accidents, injuries or illnesses occurring in remote locations where no immediate medical attention is available.
I UNDERSTAND THAT THE DESCRIPTION OF THESE RISKS IS IN NO WAY COMPLETE AND THAT ALL SUCH DANGERS, BOTH ANTICIPATED AND UNANTICIPATED, CAN LEAD TO ILLNESS, INJURY, PERMANENT DISABILITY, DROWNING OR DEATH.
I acknowledge that I have read and agree to the Waiver of Liability and Medical Consent statements
Electronic Release
I permit my child and/or myself to be included in the camp group picture, general pictures, and/or video recordings to be featured on electronic or printed media for camp promotional purposes.
I agree
Any additional Information
Food Donation
Would you like to donate to offset food costs?
(Required)
Yes
No
Donation for Food Costs
If you would like to donate to the food costs, please enter a dollar amount above.
Total
Credit Card
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