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
Email address *
First and Last Name *
Birthdate *
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Gender *
Full Address (Address, City, State, and ZIP) *
Cell Phone *
Emergency Contact, Relationship to Individual, Home Phone and Cell Phone. *
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") *
Immunizations up to date? *
Last tetanus booster *
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Any medication allergies? If yes, please specify. *
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Any food allergies? If yes, please specify. *
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Any special dietary needs? If yes, please specify. *
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Do you have any of the following: (Check all that apply) In the "other" box please explain any that have been checked. *
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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.
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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.
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Will you be bringing an inhaler to camp? *
Will you be bringing an epi-pen to camp? *
COVID-19 WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT In consideration for BEING at A RURAL BIBLE CRUSADE EVENT (hereinafter called “RBC”), I, on behalf of myself and any minor child/children for whom I have the capacity to contract, hereby acknowledge and agree to the following: 1. I understand the hazards of the novel coronavirus (“COVID-19”) and am familiar with the Centers for Disease Control and Prevention (“CDC”) guidelines regarding COVID-19 and RBC’s COVID-19 protocols. I acknowledge and understand that the circumstances regarding COVID-19 are changing from day to day, and that accordingly, the CDC guidelines are regularly modified and updated. I accept full responsibility for familiarizing myself with the most recent updates at the CDC websites. 2. Notwithstanding the risks associated with COVID-19, which I readily acknowledge, I hereby willingly choose to participate in RBC activities and abide by RBC COVID19 prevention procedures, which include the following: a. I understand that if RBC determines that a camper/volunteer/staff member needs to go home, I as the parent am responsible to pick up that person as soon possible once I’m notified.b. I understand that RBC staff will do its best to offer as many activities as possible, but that programs and procedures will look different from past years past due to COVID19 precautions. 3. I acknowledge and fully assume the risk of illness or death related to COVID-19 arising from my being on the premises and participating in the RBC activities and hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE (on behalf of myself and any minor children from whom I have the capacity to contract) RBC (Rural Bible Crusade), its affiliated officers, directors, agents, and employees, volunteers, staff, and release RBC from any liability related to COVID-19 which might occur as a result my being on the premises and participating in the RBC activities. 4. I shall indemnify, defend, and hold harmless RBC from and against any and all claims, demands, suits, judgments, losses or expenses of any nature whatsoever (including, without limitation, attorneys’ fees, costs, and disbursements, whether of in-house or outside counsel, and whether or not an action is brought, on appeal or otherwise), arising from or out of, or relating to, directly or indirectly, the infection of COVID-19 or any other illness or injury. 5. It is my express intent that this Waiver and Hold Harmless Agreement shall bind any assigns and representatives, and shall be deemed as a RELEASE, WAIVER, DISCHARGE, AND COVENANT NOT TO SUE the above-named RBC affiliates. This Agreement and the provisions contained herein shall be construed, interpreted and controlled according to the laws of the State of Wisconsin. 6. I HEREBY KNOWINGLY AND VOLUNTARILY WAIVE ANY RIGHT TO A JURY TRIAL OF ANY DISPUTE ARISING IN CONNECTION WITH THIS AGREEMENT. I ACKNOWLEDGE THAT THIS WAIVER WAS EXPRESSLY NEGOTIATED AND IS A MATERIAL INDUCEMENT THE PERMISSION GRANTED BY RELEASEES TO BE ON PREMISES AND PARTICIPATE IN THE ACTIVITIES. IN SIGNING THIS AGREEMENT, I ACKNOWLEDGE AND REPRESENT THAT I have read the foregoing Waiver of Liability and Hold Harmless Agreement, understand it, and sign it voluntarily as my own free act and deed; no oral representations, statements, or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent; and I execute this Agreement for full, adequate, and complete consideration, fully intending to be bound by same. IN WITNESS WHEREOF, I have signed this Waiver and Agreement. *
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.
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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. *
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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.
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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.
A copy of your responses will be emailed to the address you provided.
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