Name

Gender

Male
Female

Gender Queer

Pronoun Preference

Date of Birth

Confirm Email

Phone Number

Yes, it's okay to send me text messages including confirmations, changes, updates, and/or promotions. Message frequency varies. Message and data rates may apply. Reply STOP to cancel. View our terms of service & privacy policy.

Home Address

Date of Birth

Name of camp session you are volunteering with

Name of Directors for Your Session

Name of the church where you are a member

Will you be eligible for a 5, 10, or 20 year jacket this year? If so, please enter your size and tell us 5, 10, or 20 to the right.

Tshirt Size (Adult S to 5XL)

Allergy Information

If you checked "other food", "medicine", "environmental" or "other" please share those here. Also tell us what the reaction looks like and how it is treated.

Diet/Nutrition

Please describe any special food needs here.

Medical Information

Please provide some basic health information in case of an emergency. All fields in this section are required. If the question does not apply to you, simply put "none" in the box.

List any current or chronic health conditions

List any physical limitations that event directors should be aware of for planning purposes.

List all medications you will take while at camp. (Include over the counter meds.)

Are your vaccinations up to date?

Date of your last Tetanus shot

Insurance Provider and Policy and Group #'s

Emergency Contact Information

Name

Primary Phone Number

Secondary Phone

Relationship to You

Character References

Your first reference should be someone who knows you well who is not a family member.

Name

Confirm Email

Phone Number

Address

Your second reference should be the pastor of the church you currently attend.

Name

Confirm Email

Phone Number

Address

Child Protection

All potential volunteers must pass a criminal background check before being able to serve. Please review the following questions and answer truthfully below.

1. Have you been accused or convicted of a crime(s) other than a traffic violation in the past 10 years?

2. Have you ever been accused or convicted of a crime in which a child was the victim?

3. Have you ever been criminally charged with any crime related to the mistreatment, abuse or molestation of children?

4. Have you ever been accused of harassment of any person, including, but not limited to: sexual, racial, or religious?

If you answered yes above, please explain

Authorizations

I understand that I plan to volunteer at a session of camp at the Christian Conference Center. This permission is given by me with full knowledge of the conditions and activities contemplated during each session (see uppermidwestcc.org for more information). I have no physical or mental disabilities that would impair my participation except as noted above. I acknowledge, agree to, reconfirm, and incorporate herein by reference the Release of Liability signed by me which is attached hereto. I also understand that the information provided on this form will be kept confidential and shared only as necessary to provide care to myself.

I understand that camp insurance is a supplemental policy only. It will pay whatever my own insurance does not cover (deductible or over) up to the limit of the policy. If medical (sickness. injury) care is needed, billing will be sent to the person who will be responsible for direct payments to physician, hospital, clinic, etc. I am currently taking only medications listed above. I have no allergies known to me except as noted on this form. The health information/history is correct as far as I know. In the event of illness or injury, I authorize the camp, physician, and/or hospital to undertake such treatment of and perform such services (including surgical) for myself as are reasonably indicated by the circumstances.

By typing my name here I accept these terms and conditions.

Unless checked below, I accept that my likeness may be used in any online or print publications or social media by the Christian Conference Center and/or the Christian Church in the Upper Midwest.

I DO NOT give my consent.

CCC Volunteer Registration Form

General Information

Allergy Information

Diet/Nutrition

Medical Information

Emergency Contact Information

Character References

Child Protection

Authorizations