A Voice of Love and Hope for Those with Disabilities
SCHOOL YEAR EVENTS
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Coach / Volunteer Registration – School Year Events
rlynn90
2017-09-01T15:23:45+00:00
Coach/Volunteer Registration Form - School Year Events - 2017-2018
Items with an asterisk " * " are REQUIRED.
Please have your personal and medical information ready to go. Your Coach/Volunteer Registration Fee covers your T-Shirt, Lanyard and Background Check (if over the age of 18). It's your responsibility to complete the
background check
form after submitting your Coach/Volunteer Registration Form.
1
Volunteer Information
2
Health and Insurance Information
3
Personal Information
4
Policies and Releases
COACH/VOLUNTEER INFORMATION:
Coach/Volunteer Name
*
First
Last
Have you previously registered as a Coach/Volunteer?
No
Yes
If so, for whch event?
(example: Lenexa Day Camp 2015)
Best email address to communicate about this Registration?
*
Please enter email address twice. This technique makes sure you entered it correctly. Thanks!
Enter Email
Confirm Email
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Send Us a Photo
(Browse to a photo on your drive. This will help us know you.)
Accepted file types: jpg, gif, png.
Home Church
*
Age (when the event starts)
*
13
14
15
16
17
18 or older
Current Grade (at start of camp)
*
Sex:
*
Male
Female
Other contact(s) Champions might need (please supply at least one contact's information):
*
Mother
Father
Both
Other
Mother's Name
First
Last
Mother's Home Phone
Mother's Cell Phone
Mother's Employer
Mother's Work Phone
Mother's Email Address
Enter Email
Confirm Email
Father's Name
First
Last
Father's Home Phone
Father's Cell Phone
Father's Employer
Father's Work Phone
Father's Email Address
Enter Email
Confirm Email
Who to contact if an emergency?
*
Mother
Father
Both
Alternate contact (add information below)
Alternate Emergency Contact
*
Include Name, relationship to Volunteer, and phone contact information...
HEALTH AND INSURANCE INFORMATION:
Primary Insured Family Member
*
Employer
*
Name of Insurance Company
*
Policy Number
*
Group Number
*
Telephone Number on Back of Card
*
Format = (###)###-####
Medicaid Number (if applicable)
Date of Last Tetanus Shot
*
format = ##-##-####
Do you have any medication allergies?
*
No
Yes
Please list/detail any medication allergies:
Do you take any medication on a regular basis?
*
No
Yes
If yes, what medications? Please explain.
Do you have any special skills you'd like to mention (worship leading, vocalist/instrumentalist, photographer, etc.)?
*
No
Yes
Please list/explain any special skills you'd like to mention (worship leading, vocalist/instrumentalist, photographer, etc.)
PERSONAL INFORMATION
Please answer the following questions honestly and thoroughly.
Why do you want to work at Champions Day Camp?
*
Have you ever worked with individuals with Special Needs before?
*
No
Yes
Tell us about your experience working with individuals with Special Needs:
What 3 words describe you?
*
Briefly describe your walk with Christ:
*
POLICIES; HEALTH RELEASE; MEDIA RELEASE
Please carefully read each statement below. You'll be asked to initial each section using your mouse or touch screen, and to sign and date the document before you Submit.
Medication at the Event
Prior to event, you will receive a medication form. You will be able to provide specific details on how and when to administer medication. The policy regarding medication is as follows: • Keep all medication in its original pharmacy labeled bottle or its original over-the-counter packaging. The medical staff will not dispense any medications not in its original container. This policy includes vitamins and herbs. • Place medication bottle or original over-the-counter package in a labeled Ziploc bag. • Include the medication form in the Ziploc bag with the medication you'll need. • Bring your medication with the form to the event.
Cell Phone
Cell phones are not allowed during the event except for emergency situations. During the event your focus should be on your Champion. Using a cell phone will hinder your opportunity to develop a relationship with him or her. Please do not share your cell phone number with your Champion. Difficult situations can arise if your Champion begins to call you repeatedly. If asked, simply say that it is not a good idea to share cell phone numbers.
Attire
Please wear appropriate clothes for the season of year and the nature of the activity. If wearing shorts, please make sure they are modest length. Please do not wear flip-flops; tennis shoes or secure sandals like Charco's are required.
Training
When you are accepted, we'll give you Training dates and times. if you are unable to attend Training, please notify Alison Gromer (alison @ ChampionsSpecialMinistries.org). Schedules and other information that will help prepare you in your volunteer role will be given to you at training time.
Volunteer Hours
Participation in the Champions program can be used for volunteer service hours.Champions Special Ministries will provide a certificate of service at the end of the program if you request it.
Policies - Initial
*
I have carefully read and understand the above Champions Special Ministries Inc. policies. I agree with the policies and will inform my camper of the rules and policies of camp. (Initial using your mouse or touchscreen.)
Release of Liability - Initial
*
I understand that Champions Special Ministries Inc. is NOT responsible for loss of clothing or personal property while at events. I agree to bring all articles of clothing and personal property clearly marked with my first and last name. I understand that part of the day camp experience involves activities, group social arrangements and interactions. These activities and interactions may come with certain risks or uncertainties, and I am aware of these risks. I realize that no environment is risk-free, and I understand risks are minimized when following the rules as instructed by the camp staff. These rules are made to insure safety for all and I agree to follow all rules. I hereby, and for my heirs, executors, and administrators, assigns and all legal guardians, waive and release any and all rights and claims of any nature I may have against Champions Special Ministries Inc., its directors, collectively and individually, employees, Board of Directors, coaches, campers and cooperating entities for and against any and all injuries and damages of any nature, including death, which I may suffer while taking part in Champions Special Ministries Inc. Day Camp or other activities associated with Champions Special Ministries Inc. I HAVE CAREFULLY READ, UNDERSTAND AND AGREE WITH THE CHAMPIONS SPECIAL MINISTRIES, INC., RELEASE OF LIABILITIES. (Initial using your mouse or touchscreen.)
Medical Authorization and Privacy Agreement - Initial
*
I hereby give permission to the physician selected by the Camp Director to order routine medical tests, X-rays, and treatment for emergency health concerns in the event that the parent/guardian cannot be reached. I give the members of the camp medical team permission to administer over-the-counter medications as needed and to give scheduled medication as ordered on the Medication Instruction Form. I realize the camp has a limited liability medical policy for volunteers with a $2,500 maximum limit, covering only trauma, not illness. Any medical expenses in excess of this amount will be my responsibility. I authorize any physician, nurse or other health care provider to communicate with the camp medical staff and any Director of Champions Special Ministries, or his/her designee, concerning my medical condition, treatment and/or prognosis. I HAVE CAREFULLY READ, UNDERSTAND AND AGREE WITH THE CHAMPIONS SPECIAL MINISTRIES, INC., MEDICAL AUTHORIZATION AND PRIVACY AGREEMENT. (Initial using your mouse or touchscreen.)
Media Release - Initial
*
I realize that photographs and films of camp activities may be taken and used for fund-raising and publicity purposes. I hereby give my consent to Champions Special Ministries Inc., its officers, employees, agents, chapters, assignees, licensees and cooperating entities, to use my picture, name, portrait, likeness, writings or biographical information, and/or audio tape for editorial, educational, promotional and advertising purposes, for the solicitation of contributions and for any other purposes in furtherance of the corporate purposes and objectives of Champions Special Ministries, Inc. This release and consent shall be binding upon my child’s heirs, executors, administrator, assigns, and all legal guardians of my child. I HAVE CAREFULLY READ, UNDERSTAND AND AGREE WITH THE CHAMPIONS SPECIAL MINISTRIES, INC., MEDIA RELEASE. (Initial using your mouse or touchscreen.)
Authorization for Background Check (required for Volunteer Staff over 18)
INFORMATIONAL: All volunteers age 18 and older on the date of the school year program event must complete a separate Background Check Release, authorizing the investigation of any or all statements provided during the process of this application, releasing the organization from all liability for any damages for issuing this information concerning my background. You'll also authorize the investigation of any or all statements provided during the process of this application, and release the organization from all liability for any damages for issuing this information concerning my background records. It's your responsibility to access and complete the Background Check Release form on the Champions web site - - on the menu under School Year Programs
Parent/Guardian's Full Signature and Date
*
I HAVE CAREFULLY READ, UNDERSTAND AND AGREE WITH ALL POLICIES AND STATEMENTS IN THIS CHAMPIONS SPECIAL MINISTRIES, INC., VOLUNTEER REGISTRATION FORM. (Add your signature below with your mouse or touchscreen.)
Volunteer's Full Signature
*
I HAVE CAREFULLY READ, UNDERSTAND AND AGREE WITH ALL POLICIES AND STATEMENTS IN THIS CHAMPIONS SPECIAL MINISTRIES, INC., VOLUNTEER REGISTRATION FORM. (Add your signature below with your mouse or touchscreen.)
Today's Date
*
(Legal Signature requires you to choose today's date.)
Coach/Volunteer Staff 18 and older
*
This $20 fee is for your Background Check form. It's your responsibility to complete the
Background Check Release
form; see the web site under the Serve page.
Price:
$20.00
