5 Star Bible Camp 2018 Helper/Counselor Application
5 Star Bible Camp is July 16—July 22, 2018 at Camp Jefferson. This year's theme is "Shipwrecked - Rescued by Jesus!!"
The camp is free and all children are welcome!

Pre-K - 3rd Grade Camp: July 16th - July 18th, 1:00 pm to 6:00 pm. Registration is Monday, July 16th at 12:30 pm (No
meal provided - Snack only.) Open to children 5 years old (by July 16th, 2018) - 3rd grade (4 year old children welcome
with an attending parent/guardian)

4th - 6th Grade Camp: July 16th - July 18th (Overnight) Registration is Monday, July 16th at 8:30 am. Open to children who
have completed 4th to 6th grades.

7th-12th Grade Camp: July 19th - July 22nd (Overnight) Registration is Thursday, July 19 at 9:00 am. Open to youth who
have completed 7th-12th grades.

All registrations are due by June 30th, 2018.
Isaac Phimvongsa *
Your answer
Social Security Number XXX-XX-XXXX *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
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Phone Number (XXX) XXX-XXXX *
Your answer
Date of Birth MM/DD/YYYY *
Your answer
Male or Female *
Emergency Contact Person's Name *
Your answer
Emergency Contact Phone Number (XXX) XXX-XXXX *
Your answer
I am applying for (check all that apply) *
Required
If other...please specify area of interest
Your answer
Please describe available times. (Days and Hours you will be available) Please note that if you are a counselor, you need to be at camp during that designated time. *
Your answer
I will be available Sunday afternoon to set up.
Please list previous work with children. Include Church Work. *
Your answer
The following must be completed: Have you ever been convicted of or pled “no contest” to any felony including child abuse or any crime involving actual or attempted sexual abuse of a minor? *Note...The list of helpers will be sent to the Jefferson County Police Department for Background Check. *
If yes, please explain.
Your answer
Agreement: I submit that the above information is correct to the best of my knowledge. I understand that the camper is my greatest responsibility at camp. I will support all the programs and leaders of the camp. I will endeavor to conduct myself in a manner that represents Christ in all situations. I will attend all Camp trainings required of me. *
Medical information: Please list any prescription medication you are currently taking or other medical information we need to know about you. *
Your answer
T Shirt Size *
You will be contacted by the person overseeing your area of interest to let you know about meetings prior to camp and other pertinent information.Thank you for your interest in 5 Star Bible Camp and for sharing the message of Jesus with the children/youth of our area.
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