Camp JIM C.I.T. Form
Camp Dates: August 4th @ 4 pm - August 9th @ 11 pm, 2019
Camp Address: 1026 Camp Jim Rd SW, Pillager, MN 56473
Contact us at (763) 689-2667 or campjesusismine@gmail.com
Camp Director: Cubby Westerberg

This year at Camp, we are allowing responsible 12th graders to be C.I.T.'s (Counselor's in Training). They will co-counsel with an adult counselor in a cabin, or they will be able to help with the Cutie Pies Camp. C.I.T.'s are required to complete this form and to have a positive recommendation from a pastor or elder in their church.
First Name *
Your answer
Last Name *
Your answer
Gender *
I am entering 12th grade Fall 2019 *
Email *
Your answer
Best Contact number *
Your answer
Address *
Your answer
Which position(s) are you interested in? *
Required
Please write your testimony of how you became a Christian. Explain why you are confident that you are a Christian. 1-2 paragraphs. *
Your answer
Please explain why you want to be a C.I.T. this year. 1 paragraph. *
Your answer
T-Shirt Size
T-Shirt Fee: $10. Please make checks payable to NWBA Camp JIM or your Church. (T-Shirts are not required)
Health Information
Emergency Contact Name *
Your answer
Emergency Contact Number *
Your answer
Relation to CIT *
Your answer
Insurance Company *
Your answer
Insurance Policy Number# *
Your answer
Policy Holder's Name *
Your answer
Policy Holder's DOB *
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Group Number# *
Your answer
Name of Family Dr. *
Your answer
Clinic *
Your answer
Please list any health conditions we should be aware of *
Your answer
Dietary Restrictions *
Medications
Medications brought by counselors in training (CIT's) must be placed in a Ziplock bag in the original container with the CIT's name and instructions clearly marked on bag.
Please list any health conditions we should be aware of *
Your answer
I understand that I must receive a pastor recommendation to be a CIT at camp *
Email this link to your pastor/elder/deacon to receive your recommendation: https://goo.gl/forms/J9CWcTvUyd5wPsXl1
Required
Parental and CIT Agreement
I HEREBY:

1. Give NWBA Camp JIM permission for my child to attend camp and serve as a Counselor In Training (CIT). I understand that any CIT disregarding camp policies may be sent home at parent's expense, without refund. She/he may be photographed/recorded; pictures, audio, and/or video may be used for camp promotional material.

2. Understand that every effort will be made to protect and safeguard all participants. I will not hold staff or volunteers of Camp JIM/NWBA Camp JIM liable for any illness or mishap which may be sustained. I give permission for my child to participate in Camp JIM sponsored events which my be held on/off the immediate campgrounds.

3. Request that in the event of an emergency, my son or daughter be taken (by ambulance, if deemed necessary) to the nearest doctor or hospital for examination and or treatment and I will be notified immediately. I understand that Camp JIM/NWBA Camp JIM is not responsible for any medical expenses not covered by my insurance, including ambulance expenses.

4. Understand that certain medical conditions such as pregnancy, fever or certain contagious conditions may not allow my son or daughter to participate as a CIT.

5. Understand that being a counselor/volunteer automatically makes me a role model to all the kids at Camp JIM, and I will seek to display the example of Christ in my speech, conduct, and attitude while at Camp JIM.

6. Understand that as a volunteer, I must complete volunteer training. More info will be provided after you sign up.

7. That smoking and the use of drugs is strictly prohibited on Camp JIM camp grounds.

8. That a background check is necessary for all volunteers and agree to a background check.

9. I understand the Camp JIM is free for volunteers. But if you would like to help offset the cost of camp, you may make a donation for any amount to NWBA Camp JIM.
Parent Signature
Your answer
CIT Signature
Your answer
Date
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Submit
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