Rural Bible Crusade of Wisconsin Staff Agreement and Health Form
Staff agreement and health form for Rural Bible Crusade of Wisconsin's camp, retreat, and Vacation Bible School (VBS) staff and volunteers.


“The earth is the Lord's and the fullness thereof, the world and those who dwell therein, for He has founded it upon the seas and established it upon the rivers.”
Psalm 24:1-2

First and Last Name *
Your answer
Birthdate *
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Gender *
Full Address (Address, City, State, and ZIP) *
Your answer
Cell Phone *
Emergency Contact, Relationship to Individual, Home Phone and Cell Phone. *
Your answer
Please list: Insurance Company, Phone number, Address, City, State, Zip, Policy Holder Name, Date of Birth, Relationship to Staff, Policy Number, and Group Number (If not covered type "none") *
Your answer
Immunizations up to date? *
Last tetanus booster *
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Any medication allergies? If yes, please specify. *
Required
Any food allergies? If yes, please specify. *
Required
Any special dietary needs? If yes, please specify. *
Required
Do you have any of the following: (Check all that apply) In the "other" box please explain any that have been checked. *
Required
Will you be bringing any prescription medications? If yes, please list them in the "other" area. *
*If you are bringing any medications to camp they MUST be locked in a vehicle at all times.
Required
Will you be bringing over the counter medications? If yes, please list them in the "other" area. *
*If you are bringing any medications to camp they MUST be locked in a vehicle at all times.
Required
Will you be bringing an inhaler to camp? *
Will you be bringing an epi-pen to camp? *
RURAL BIBLE CRUSADE OF WISCONSIN ACKNOWLEDGEMENT & ASSUMPTION OF RISK WAIVER AND RELEASE: Upon careful reading and consideration I, ____________________ (Volunteer/Staff) recognize that some activities carry the risk of injury. *
Your typed name at the end of this document completes this question.
Required
You hereby attest as follows: By signature below, I acknowledge that I will participate in Rural Bible Crusade of Wisconsin activities, programs, and related events. I understand that participation in these activities, programs, and related events is not without risk. I will release, hold harmless, and indemnify Rural Bible Crusade of Wisconsin, its board, staff, and/or volunteers for any harm, injury, or death caused by my participation with RBC. I understand that no activity program is absolutely safe and free of risk. Rural Bible Crusade of Wisconsin reserves the right to use any pictures taken of me at Camp/Retreats/VBS to promote the ministry.I understand that this is a volunteer/unpaid position. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment or volunteer relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment/volunteer relationship may not be changed by any written document or by conduct unless such changes is specifically acknowledged in writing by an authorized executive of this organization. *
If I need medical attention while participating, it is my wish that the treatment be begun while efforts are being made to contact my emergency contact. So that treatment is not delayed, I consent to any medical procedures that the Rural Bible Crusade of Wisconsin staff and/or physician believes needed, on the understanding that efforts will continue to be made to contact my emergency contact. I accept responsibility for all cost related to such treatment. *
Required
Rural Bible Crusade of Wisconsin also reserves the right to use any pictures taken of you at Camp/Retreats/VBS to promote the ministry. *
My signature at the end of this document verifies that... *
*All of these documents/video (Child Protection Policy, Staff Conduct Policy, and Doctrinal Statement, and Keeping Children Safe and Secure Video) may be accessed at http://www.ruralbiblecrusade.org/forms-staff-training/. If you are unable to access them please contact the Rural Bible Crusade of Wisconsin office at jdcrbc@gmail.com or 715-384-4944.
Required
I have had sufficient opportunity to read this entire document and other documents/video listed above. I have read/watched and understood them, and agree to be bound by the terms. *
By typing your name you are signing your legal electronic signature and are thus agreeing to be bound and abide by Rural Bible Crusade of Wisconsin's terms and conditions. This signature is valid for the entirety of this document.
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