Counselor Application 2018 July 9 th 13 th Name Address City State & Zip Home Phone Cell Phone E-mail address Male Female Birth Date (mm/dd/yy) Age (at camp) Emergency Contact Name Phone Relation to Camper T- Shirt Size: Youth: S M L Adult: S M L XL XXL What would make you a good camp counselor: What experience do you have working with children?
Confidential This application will be kept in a locked cabinet with access only to the appropriate Crestview staff. Full Name: Driver s License # Soc. Sec. # (Please provide a copy of your driver s license.) Have you ever been charged with, convicted of, or pled guilty to child abuse or a crime involving actual or attempted sexual misconduct or sexual molestation of a minor? YES NO Is there any other fact or circumstance involving your background that would call into question your being entrusted with the supervision, guidance, and care of minors. YES NO If yes, please explain: Personal References: Name: Phone: Address: Name: Phone: Address: Applicant s Statement: The information contained in this application is true and correct to the best of my knowledge. I understand that some of the information that I have given will be verified, and this verification will include an inquiry into my criminal history. I authorize any of the above references or churches to give you any information that they may have regarding my character and fitness to work with children. I release from all liability any person or entity requesting or supplying information with respect to my application. I agree to be bound by the policies of Crestview Church of Christ and to refrain from unscriptural conduct in the performance of my services on behalf of the church. Signature: Date:
MEDICAL CONSENT FORM Name of Youth Birth Date Address_Phone # ( ) City State Zip Mother s Work Phone # ( ) Father s Work Phone # ( ) Emergency Contact Person Relationship Emergency Phone # ( ) Parent s Cell Phone # ( ) Health Insurance Company Insurance Phone # ( ) Policy Number Group Number Family Physician P hone # ( ) (Please use the reverse side to list any allergies, current medicines and/or special attention your child needs.) The undersigned does hereby give permission for our (my) child,, to attend and participate in activities sponsored by the Crestview Church of Christ, Waco, Texas. We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act or the medical staff of an accredited hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. Should it be necessary for our (my) child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs. The undersigned does also hereby give permission for our (my) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by the Crestview Church of Christ. Should my child ride in a vehicle other than Crestview s to or from any trip or activity, the undersigned will give special consent for the transportation in this vehicle for any trip or activity, and notify the trip s supervisor(s). The undersigned understands that said minor will be chaperoned both in route and during any activities sponsored by the Crestview Church of Christ and the normal precautions will be taken in the interest of the minor s safety. The undersigned agree(s) that the sponsors and chaperons will not be held responsible for any accidents or misfortune that may occur in connection with said activities during the year. Parent Signature Date Legal Guardian Signature Date
Brookhaven Retreat Medical Consent Form Name: Birthdate: Sex: Age: Parent/Guardian:_Phone: Home Address: If not available in emergency notify: 1. Name: Phone: 2. Name: Phone: Please furnish current health insurance with policy number covering camper. Health Insurance Company: Policy Number: I certify that this camper is in good health to the best of my knowledge and from past health examinations. I hereby give my permission for my child to engage in all camp activities, including the Ropes Course and water activities, except noted by me (attach.) In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for my child as named on this form. I further agree that I will not hold Brookhaven Retreat, its staff or Board of Directors, responsible in the event of any accident, altercation, or emergency involving my child while at or in route to or from Brookhaven. Signature: Date: HEALTH HISTORY CHECK THOSE APPLICABLE GIVING APPROXIMATE DATES Allergies: Diseases: Ear Infections: Hay Feaver:: Chicken Pox: Rheumatic Feaver: Ivy Poisining: Measles: Convulsions: Insect Sting: German Measles: Diabetes: Penicillin: Mumps: Behavior: Other Drugs: Ashtma: Foods: IMMUNIZATION HISTORY Required immunizations must be determined locally. This is a record of dates of basic Immunizations and the most recent booster doses. DTP Series: Booster: Tetnus Booster: Polio OPV (Sabin): Booster Typhoid: Measles Vaccine (live): Tuberculin Test German Measles (rubella): Mumps Vaccine (live): Small Pox: Other: Additional Comments:
Each person must read, sign, and turn in this form to be allowed to participate in any Brookhaven Retreat activities. Please make as many copies of this form as needed. Brookhaven Retreat Assumption of Risk and Release WHEREAS, THE UNDERSIGNED wishes to voluntarily participate in activities organized by Christian Mission Connection DBA Brookhaven Retreat, of Hawkins, Texas: In consideration of Brookhaven Retreat s action in allowing the undersigned to participate in such a program: I, the undersigned, acknowledge that during the said program in which I am requesting to participate, certain risks and dangers may occur. These include, but are not limited to: the hazards of depending on other people; being at various heights (ground to 50 ); accident or illness in remote places where medical facilities may be more than one hour away; the forces of nature; and travel by air, train, boat, automobile or other conveyance to or from Brookhaven Retreat and while at the facility. The undersigned further recognizes that these risks may also include: loss or damage to personal property; physical or psychological damage and/or injury not excluding fatality due to accidents that may occur; and accidents resulting from challenge course experiences and other types of outdoor activities. In consideration of, and as part payment for the right to participate in such a program and the services and food arranged for me by Brookhaven Retreat, Directors, Officers, Employees, Agents, and/or Associates, I have and do hereby assume all the above risks which are not specifically foreseeable, and will hold them harmless from any and all liability, actions, causes of action, debts, claims and demands of every kind of nature whatsoever, whether for bodily injury, property damage or loss otherwise, which I now have or which may arise from or in connection with my participation in any other activities arranged for me by Brookhaven Retreat, Directors, Officers, Employees, Agents, and/or members of my family, including any minors accompanying me. In short, I will not sue Brookhaven Retreat. However, I the undersigned do reserve the right of arbitration, if necessary, to settle any and all grievances that might arise during this program. I also state that I am not under, and will not be under the influence of any chemical substance, including alcohol. I fully understand that my physical activity involves risk of injury. I also understand that my participation in this Brookhaven Retreat, program is entirely VOLUNTARY. I enter into this program and take full responsibility for my decision to participate or not to participate and agree to follow all safety instructions. Anyone with any of the following conditions (but not limited to) should not participate in high ropes, zip line, or trapeze activities: Pregnancy; recent surgery; back, neck, or shoulder problems; heart condition; high blood pressure; recent severe injury. The undersigned further certify that photographs, video footage, or audio clips of the undersigned participant taking part in programs at Brookhaven Retreat may be reproduced and utilized in promotional materials for Brookhaven Retreat, and that no person shall be compensated for this use. Retreat Group Name Print Participant Name Retreat Dates Signature of Participant (if over 18 yrs old) Parent/Legal Guardian Signature (must sign for all persons under age 18) Today s Date