Name *

First Name

Last Name

Home Phone

(###)

###

####

Cell Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthdate *

MM

DD

YYYY

Emergency Contact

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Are you CPR Certified? (Please provide proof of certification)

Yes

No

Are you medically trained?

Yes

No

Would you like to order a FAC T-shirt for $10? Payment is due at our final meeting on June TBD 2024.

Yes

No

The questions listed below are a part of our screening process that enables us to provide a safe and secure environment for our children. All information is kept strictly confidential by the FAC staff. Answering yes to any of the questions may not necessarily preclude your involvement in FAC. Thank you for your honesty. Have you ever been investigated, accused, suspected, indicted or convicted of any abuse or sexually related crimes? *

Yes

No

Have you ever abused or molested a minor in any way, regardless of whether there was any criminal investigation or conviction? *

Yes

No

Do you use illegal drugs? *

Yes

No

Is there anything about you or your life that would call into question your Christian witness? *

Yes

No

The information contained in this application is correct to the best of my knowledge. I understand that any omission of material fact on this application may be grounds for rejection of this application and/or termination of FAC responsibility. I understand that the personal information will be held confidentially by the camp staff. Should my application be accepted, I agree to follow the policies and procedures of Faith Adventure Camp and to refrain from unscriptural conduct in the performance of my duties on behalf of the camp. *

First Name

Last Name

Digital Signature provided on: *

MM

DD

YYYY

Name *

First Name

Last Name

Birthdate

MM

DD

YYYY

Gender *

Male

Female

Parent, Guardian or Spouse

First Name

Last Name

Alternative phone

(###)

###

####

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

In case of an emergency please notify

First Name

Last Name

Phone

(###)

###

####

Alternative Phone

(###)

###

####

Emergency Contact Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Did you receive the standard childhood immunizations?

Yes

No

Date of last tetanus (DpT) immunization

MM

DD

YYYY

Current regular medications?

Yes

No

Dietary modifications?

Yes

No

Name of family physician

First Name

Last Name

Physician's phone number

(###)

###

####

The information contained in this application is correct to the best of my knowledge. I understand that any omission of material fact on this application may be grounds for rejection of this application and/or termination of FAC responsibility. I understand that the personal information will be held confidentially by the camp staff. Should my application be accepted, I agree to follow the policies and procedures of Faith Adventure Camp and to refrain from unscriptural conduct in the performance of my duties on behalf of the camp.

First Name

Last Name

Digital Signature provided on:

MM

DD

YYYY

Name *

First Name

Last Name

Cell Phone

(###)

###

####

Home Phone

(###)

###

####

When would you prefer to have free time?

Morning

Afternoon

Name *

First Name

Last Name

Cell Phone *

(###)

###

####

Date

MM

DD

YYYY