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Cart
0
JumpIn Prayer House
Prayer House
About Us
Beliefs
Children and kids
Events
Father Child Survival Overnighter
Health Forms
Get Involved
Donate
Summer Staff Information
Summer Staff Application
Return Summer Staff Application
Background Check
Summer Staff job offer Form
Summer Operations Staff job offer Form
Summer Staff Health Form
Blog
Contact
Summer Staff Health Form
Parent or Guardian Name
*
First Name
Last Name
Phone
*
(###)
###
####
Email
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Name of Second Parent or Guardian
*
First Name
Last Name
Phone of Second Parent or Guardian
*
(###)
###
####
Emergency Contact
*
If Parents or Guardian Cannot be Reached
First Name
Last Name
Emergency Contact Phone Number
*
(###)
###
####
Medical Insurance Provider
*
Policy Number
*
Medical Waiver
*
Medical Waiver By electronically signing this document below, I hereby verify that the below information is complete and accurate to my knowledge. I hereby grant permission to receive first aid and emergency treatment by JumpIn NW Program personnel in the event of injury, or by the hospital emergency room, for a life-saving decision if emergency contacts cannot immediately be reached. I voluntarily waive any claim against JumpIn NW personnel, or other persons transporting me, against all liability, claims, damages, attorney fees, or expenses arising out of or in connection with any activities of the above-mentioned organization.
Photography Release
*
Photography Release * If I am in a photograph taken by Jump-In NW designated staff the photograph may be used in publications on-line or in print for advertising purposes.. Jump-In NW will not include the name of our staff on any publications or sell merchandise with your photo. Jump-In NW will not share your photo with any business. It is for the exclusive use of Jump-In NW Camp publications and advertising.
Photos of me may be included in Jump-In NW publications.
I do not want to have photos taken by Jump-in NW used in publications.
Name of Summer Staff Member
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Is Tetanus Shot Current?
*
YES
NO
Date of Last Known Tetanus
MM
DD
YYYY
List any Allergies and your reaction to that Allergy
Medications you need at camp
This will be confidential and only known by Sr. Staff. You will administer the medications yourself and keep them in your room away from campers. If an emergency does arise it may be helpful to know what medications you are taking.
Thank you!
