Sixth Grade Camp Guest Counselor Form 2011-2012

Please complete the following fields to complete the Indian Hills Camp Sixth Grade Camp Guest Counselor Registration process  All fields marked with an (*) are required.  Once the form is completed, press the "Submit" button at the bottom of the page.  IF THIS FORM IS NOT COMPLETED IN FULL AND NOT SUBMITTED, NO INFORMATION WILL BE SAVED.  Thank you.

 

School Name	*
GENERAL INFORMATION
Counselor's First Name	*
Counselor's Last Name	*
Gender	*	Female Male
Birth Date	*	January February March April May June July August September October November December* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31*
Age	*
Address	*
City	*
State	*	- - Choose One - - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip	*
Home Phone (xxx-xxx-xxxx)	*
E-mail	*
Confirm E-mail	*
Other		Skip to Next Field
Is this the FIRST TIME you will be attending camp at IHC as a counselor?	*	Yes No
Other		Skip to Next Field
HEALTH HISTORY INFORMATION
Medical Insurance
Health Insurance Carrier	*
Policy #	*
Doctor
Doctor Phone (xxx-xxx-xxxx)
Immunization Information
IMPORTANT: The State of California requires that every camper/counselor submit the following immunization information. If you have not been immunized, please choose N/A in the month box and type N/A in the year box.
DTaP (tetanus):	*	January February March April May June July August September October November December N/A*
MMR:	*	January February March April May June July August September October November December N/A*
Hep B:	*	January February March April May June July August September October November December N/A*
Varicella:	*	January February March April May June July August September October November December N/A*
Additional Immunization Information:		Had Chicken Pox Disease (please indicate month and year in Varicella box)
Current Health Conditions
Please mark all that apply.		Heart Condition ADHD Diabetes Asthma Epilepsy
Current Medications
Current Illness/Injury
Food Allergies
Medication Allergies
Environmental Allergies
Diet Restrictions
Activity Restrictions
Other
In a case of emergency, please notify:
Name	*
Home Phone (xxx-xxx-xxxx)	*
Work Phone (xxx-xxx-xxxx)
Cell Phone (xxx-xxx-xxxx)
Name	*
Home Phone (xxx-xxx-xxxx)	*
Work Phone (xxx-xxx-xxxx)
Cell Phone (xxx-xxx-xxxx)
Skip to Next Field
BACKGROUND CHECK INFORMATION AND AUTHORIZATION:
Former Names and Year Changed:
Current Address:	*
	*	*- - Choose One - - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY *
Current Address Since:	*	- - Choose One - - January February March April May June July August September October November December *
Previous Address:
		- - Choose One - - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Previous Address Since:		- - Choose One - - January February March April May June July August September October November December
Social Security Number:	*	* *
Driver's License Number and State:	*	*- - Choose One - - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Release Waiver and Indemnity Agreement
For and in consideration of permitting myself to observe, or use any facility or equipment of Shiloah Springs Bible Retreat, Inc. d/b/a “Indian Hills Camp” (“IHC”), or engage in and/or receive instruction in any activity or activity incidental thereto some of which may involve danger, risk of bodily injury, or death at Indian Hills Camp, I hereby voluntarily and absolutely release, discharge, waive, and relinquish any and all loss or damages or actions or causes of action for personal injury, property damage, or wrongful death occurring to myself as a result of my observing or using facilities or equipment of Indian Hills Camp, or engaging in or receiving instructions in any activities some of which may involve danger, risk of bodily injury, or death or in activities incidental thereto wherever or however the same may occur, and for whatever period said activities or instructions may continue. I, for myself, my heirs, executors, administrators, or assigns agree that in the event that any claim for personal injury, property damage, or wrongful death shall be prosecuted against Indian Hills Camp or its officers, agents, servants, or employees, the undersigned , myself, will indemnify and hold harmless Indian Hills Camp and its officers, agents, servants, or employees from any and all claims or causes of action, including attorney’s fees, by myself or by any other person or entity, by whomever or wherever made or presented, and under no circumstances will I present any claim against Indian Hills Camp and said persons for personal injuries, property damage, wrongful death, or otherwise, caused by any act of negligence by Indian Hills Camp and said persons. By checking the box to the right, I represent that I have read this release, have requested and have been provided with, or have requested and declined advisement on the potential dangers/risks of engaging in the observation, activities, or instruction offered, and am fully aware of and understand the terms and the legal consequences of the signing of this Release. I intend my checking of the box to the right to be a complete and unconditional release of all liability to the greatest extent allowed by law and if any portion of the Release is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. In addition to the Release set forth above I hereby grant permission to Indian Hills Camp to take photographs of myself throughout my stay at Indian Hills Camp. I understand that all photographs taken of me are the sole property of Indian Hills Camp and may be posted on Indian Hills Camp’s website and promotion and advertising activities of Indian Hills Camp.
Release, Waiver and Indemnity Agreement	*	I accept, understand and agree with all of the above terms.
Authorization for Treatment
I am attending and participating in activities at Shiloah Springs Bible Retreat, Inc. d/b/a “Indian Hills Camp” (hereinafter "Indian Hills Camp") located at: 15763 Lyons Valley Rd. Jamul, CA 91935, in the County of San Diego. I hereby authorize the officers, agents, servants, or employees that are 18 years of age or older of Indian Hills Camp, who supervise the activities at Indian Hills Camp into whose care I have been entrusted, to consent to medical care or dental care, or both, for myself under Sections 6901, 6902, and 6910 of the California Family Code. The authority granted by this authorization includes the authority to consent to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a physician and surgeon licensed under the Medical Practice Act for myself. This authority also extends to any x-ray examination, anesthetic, dental, or surgical diagnosis or treatment and hospital care by a dentist licensed under the Dental Practice Act for myself. I further authorize the officers, agents, servants, or employees that are 18 years of age or older of Indian Hills Camp, who supervise the activities at Indian Hills Camp to receive physical custody of myself, under Section 1283(a) of the California Health and Safety Code, upon completion of any treatment, and I specifically instruct any treating health facility to surrender physical custody of myself to the officers, agents, servants, or employees that are 18 years of age or older of Indian Hills Camp who supervise the activities at Indian Hills Camp. It is understood that this authorization is given in advance of any special diagnosis, treatment, or hospital care being required but is given to provide authority and power on the part of the supervisor or his/her authorized designee, in the exercise of his/her best judgment, upon advice of such physician, dentist, and surgeon, may deem advisable. By checking the box to the right, I represent that I have read this release, have requested and have been provided with, or have requested and declined advisement on the potential dangers/risks of engaging in the observation, activities, or instruction offered, and am fully aware of and understand the terms and the legal consequences of the signing of this Release. I intend my checking of the box to the right to be a complete and unconditional release of all liability to the greatest extent allowed by law and if any portion of the Release is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
Authorization for Treatment	*	I accept, understand and agree with all of the above terms.
Background Check Authorization
The information contained in this application is correct to the best of my knowledge. I hereby authorize Indian Hills Camp and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment and/or volunteer purposes. I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to the following areas: verification of social security number; credit reports; current and previous residences; employment history, education background and character references; drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state and/or county jurisdictions; driving records, birth records, and any other public records. I further authorize any individual, company, firm, corporation, or pblic agency (including Social Security Administration and law enforcement agencies) to divulge any and all information, verbal or written, pertaining to me, to Indian Hills Camp or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation or public agency may have, to include information or data received from other sources. **Indian Hills Camp and its designated agents and representatives shall maintain all information received from this authorization in a confidential manner in order to protect the applicant's personal information, including, but not limited to, addresses, social security numbers, and dates of birth.
Background Check Authorization	*	I accept, understand and agree with all of the above terms.
Please enter your name here to sign this release.
Electronic Signature (please enter name):	*
Security Code	*
Thank you for completing the Summer 2011 Guest Counselor form. We look forward to serving with you during your encampment.
After clicking the "Submit" button, you will either be redirected: 1.) to the top of the form because required information is missing, designated by an "*", (depending on the web browser, fields that are missing required information are typically highlighted); or 2.) to a "Thank You" web page confirming that your information has been submitted. **We look forward to seeing you at IHC**