Teen Staff Application
Please complete the application below. Email contact@campkoinoniany.org with questions.
First Name *
Your answer
Last Name *
Your answer
What name should go on your name tag? *
Your answer
Street Address *
Your answer
Street Address Line 2
Your answer
City *
Your answer
State *
Your answer
Zip+4 *
Your answer
E-mail *
Your answer
Phone Number (with area code) *
Your answer
Birth Date *
MM
/
DD
/
YYYY
Have you previously staffed at Family Camp? *
Grade you will be entering in the Fall *
Your answer
Home Parish *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone Number (with area code) *
Your answer
Emergency Contact Relationship to Teen Staff *
Your answer
Health Insurance Provider *
Your answer
Health Insurance Policy Number *
Your answer
Any medications, allergies, or health needs / concerns?
Your answer
Any dietary restrictions / requirements?
Your answer
Are your immunizations up to date? *
How many weeks would you like to staff? *
1st Choice of Weeks *
2nd Choice of Weeks *
3rd Choice to Weeks *
1st Choice of Age Group *
2nd Choice of Age Group *
3rd Choice of Age Group *
Parent/Guardian Signature (Have your parent input text below.) *
Your answer
Do you wish to apply for a scholarship? *
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