Camp Director or Counselor Form 2018
Camp Application for the Christian Church (Disciples of Christ) in Indiana

By completing and signing this document, you authorize the Commission on Camps and Conferences of the Christian Church (Disciples of Christ) in Indiana, to contact any persons or entities for the purpose of evaluating your fitness as a Camp Counselor or Director; any prior employers; any education institutions attended; any sponsor of a child-related or youth-related activity participated; and a criminal background check agency. Permission is given for the contact of any such person or entity and for the release of any records pertaining to my employment/service/character/general reputation/personal characteristics and mode of living. This release does not extend to financial records.

Email Address: *
Your answer
Camp Application For: *
Name(Last name, First name, name called if different) *
Your answer
Birthdate *
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Age *
Your answer
Home Address (City,State, Zip) *
Your answer
Best Number to Contact You: *
Your answer
Other Phone Contact Numbers:
Your answer
Social Security Number: *
Your answer
Name & City of Home Congregation *
Your answer
Occupation *
Your answer
T-Shirt Size *
Work/Camp Experience *
Your answer
I would like to participate at: *
Camps you prefer to participate: *
I am currently certified/qualified in:
Certifications, Special Gifts & Talents: *
Your answer
Ministers Name, Phone and Email: *
Your answer
2nd Reference Name, Phone and Email: *
Your answer
Any Health Concerns? If so, please explain: *
Your answer
Any Allergies? If so, please explain: *
Your answer
Special Food Needs? If so, please explain: *
Your answer
Any Prescription Medications? If so, please explain *
Your answer
Emergency Contact Name, Phone and Email: *
Your answer
Name of Insurance Provider *
Your answer
Full Address of Insurance Company *
Your answer
Phone Number of Insurance Company *
Your answer
Have you been convicted of a felony? *
Have you been convicted of child abuse or a crime involving actual or attempted sexual molestation of a minor? *
Signature: *
Your answer
Today's Date: *
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