Cabin Leader & Staff Application Form for Northwest District Summer Camps 2010
PO Box 1439, Bothell, WA 98041
For Kids Camp contact: Susie Horn - 425.488.2500 x311 susieh@eastsidechurch.org
For Youth Camps contact: April Nault – 425.448.2500 x227 apriln@eastsidechurch.org
Camp(s): Camp Role:
 Sr. High Camp, August 9th – 14th  Cabin Leader (must be 18 years or older)
 Jr. High Camp, August 16th – 21st  Staff __________________________________ (appointed by Directors only)
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 Kids’ Camp, August 23 – 28  Jr. Leader (specific to Kids’ Camp only, must be at least 15 years old)
*Please make sure you check the specific box as to which camp you will be participating in.
Name_________________________________________________________________________________________________________________
Gender:  Male  Female Birthday _____________/ ___________/ ____________________________
Address___________________________________________________ City __________________________ State_______ Zip____________
Phone - Home (_______)_____________________ Work (_______)________________________ Cell (_______)_________________________
Email (print neatly!) _____________________________________________________________________________________________________
Occupation ______________________________________________________ T-Shirt: AS___ M___ L___ XL___ XXL
Church: __________________________________ City: _____________________________ Length of time attended: ____________________
Have you ever been a cabin leader or support team staff at a District Camp before?  Yes  No
If yes, which one(s)? ___________________________________________________________________________________________________
KIDS’ CAMP ONLY:
If applying as a Jr. Leader: Age ___________ Have you been a Jr. Leader at a District Camp before? Yes No
*NOTE: Jr. Leaders are subject to Camp Director’s approval and are reserved for those currently serving in their church’s Children’s Ministries Department. The Applicant’s
Youth Pastor must submit the Reference Form below.
MEDICAL INFORMATION AND HISTORY (this information is used solely in the event you are incapacitated while at camp)
Date of last Tetanus Shot: __________/___________/ _______________________
Health Insurance Co.: _________________________________________ Policy # ___________________ Group # ___________________
Emergency Contact Name: ______________________________________________ Relationship: ________________________________
Emergency Contact Phone Numbers: Home (_______)______________________ Cell (_______)_________________________________
Do you have any medical conditions?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Do you have any allergies (food, drug, environmental, insect stings)?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Are you on any prescription medication?
Yes No If yes, please list medications and dosages:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
List any surgeries or serious injuries in last two years:
_________________________________________________________________________________________________

FOR CABIN LEADERS ONLY: Names of 2 campers you would like to be with during camp:_______________________________________
____________________________________________________________________________________________________________________
Give two references – two persons not related to you who have known you at least one year:
1.) Name_____________________________________________________________ Years Known ________ Phone______________________
Relationship_________________________________________________________________________________________________________
Address__________________________________________________________ City______________________ State_____ Zip___________
2.) Name____________________________________________________________ Years Known ________ Phone______________________
Relationship________________________________________________________________________________________________________
Address__________________________________________________________ City______________________ State_____ Zip___________
Due to the active nature of programming, it is necessary to be aware of the physical demands that may be required for a week of leading
and mentoring young students in various environments. Do you acknowledge the potential physical demands on your body, and believe
your current health allows you to fully participate?
Yes No If no, please explain: __________________________________________________________________________________
___________________________________________________________________________________________________________________
Are you in agreement with the doctrine of the International Church of the Foursquare Gospel? Yes No
If no, please explain: _________________________________________________________________________________________________
While recognizing that Christians may differ on the use of alcohol and tobacco, in the interest of Christian harmony, while volunteering in
any Seattle District Summer Camp, will you abstain from the use of alcohol, tobacco and/or drugs throughout your participation in our
programs? Yes No
MINISTRY INVOLVEMENT:
In what areas of your church are you presently involved with? ______________________________________________________________
What are your present devotional life practices? _________________________________________________________________________
___________________________________________________________________________________________________________________
Why do you desire to be a volunteer at camp? ___________________________________________________________________________
___________________________________________________________________________________________________________________
How would you describe your relationship with Christ? When do you feel that the relationship began? ___________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
What areas do you have experience in?
Video Sports Photography Organizational Computers Drama Crafts
 Music: Vocal Music: Instrumental* PowerPoint Sound Tech.  Other: _____________________________
*Instruments: ________________________________________________________________________________________________________
Interesting Talents:
__________________________________________________________________________________________
_________________________________________________________________________________________

SUMMER CAMP 2010
Permission Slip and Medical Release
1. Volunteer Declaration:
I will fully cooperate with the staff, rules and program established for the camp so as to not discredit my church or myself.
Volunteer’s Signature: ________________________________________________________________ Date: ________/________/________
2. Release:
I agree that I am attending the regional Northwest Foursquare District’s camps at Lake Retreat in Ravensdale, WA and agree that I am
taking part in activities provided by the camp. I acknowledge that these activities involve the risk of serious injury or death. I
acknowledge the need for responsible behavior and obedience on my part.
The program may include, but is not limited to: water activities (such as swimming, the blob, canoeing, & other activities in which people
would be using in the lake), sporting activities/all camp games/team sports/field games (such as flag football, basketball, dodge ball,
volleyball, softball, mini-golf, Frisbee-golf), paintball games, and mingling with other individuals and groups. In the event there is an off-
campus activity (such as a service project or motor activity at a lake) would you consent to your son/daughter to use the buses provided
and motor activity at the desired location. Specific activities may be excluded or added—please contact the Camp Director if you have any
questions or concerns.
I need to exclude myself from participating in: __________________________________________________________________________
___________________________________________________________________________________________________________________
I give permission for camp staff &/or to give me the following:
Acetaminophen - Tylenol or Generic: Yes No Aspirin: Yes No
Ibuprofen - Advil or Generic: Yes No Antihistamine - Benadryl or Generic: Yes No
Cough Suppressant - Robitussin or Generic: Yes No Decongestant - Sudafed or Generic: Yes No
Hydrocortisone Ointment: Yes No Antibiotic Ointment: Yes No
Antacid - TUMS, Mylanta, Maalox or Generic: Yes No
I understand that I am responsible for my actions and will be held financially responsible for any damage done by me and will pay for any
and all repairs incurred by such damage. I give permission for media shots of myself to be used for Summer Camp informational and
promotional purposes. I agree to go on camp authorized field trips away from camp premises. I understand that the payment submitted
with this application is non-refundable (contact your church about the possibility of transferring it to another volunteer). I will contact the
Camp Administrator directly to cancel participation in the camp that I would plan to attend.
Declarations
In the event of an accident or an illness during this event that needs immediate treatment, I agree to receive first aid & medical treatment
from qualified practitioners, including life-saving treatments, as may be considered necessary by a licensed medical provider.
I also authorize the transportation, by ambulance if necessary, to the nearest available medical facility.
I understand the extent & limitations of the insurance coverage as provided by the organization sponsoring the event, and that my
medical insurance is primary, unless otherwise specified.
I will inform the leaders of the event as soon as possible if there is any change in medical circumstances regarding myself between the
date signed below and the start of this event.
Signature: ________________________________________________________________ Date: _____/_____/______
By signing below, I certify that the information contained in this application is true to the best of my knowledge, and that I will abide by
the commitments I’ve made to the best of my ability, and I give the Seattle District of Foursquare Churches permission to run a
background check, including a police record check, on me.
Signature: ________________________________________________________________ Date: _______/_______/_______

Cabin Leader & Staff Application Form for Northwest District Summer Camps 2010
PO Box 1439, Bothell, WA 98041
For Kids Camp contact: Susie Horn - 425.488.2500 x311 susieh@eastsidechurch.org
For Youth Camps contact: April Nault – 425.448.2500 x227 apriln@eastsidechurch.org
CONFIDENTIAL
After filling in your name and the camp you are applying for, please have a pastor or someone in authority at your church complete
this form.
Applicant’s Name: ______________________________________________________________________________
Applicant’s Church: _______________________________________________City: _________________________
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Camp:  HS Camp, August 9 – 14  JH Camp, August 16 – 21  Kids’ Camp, August 23 – 28
The person named above is applying to be a volunteer for a Foursquare Christian summer camping program. We thank you for taking the
time to complete this character reference to better aid us in selecting quality men and women to serve as mentors and sponsor of
impressionable young lives.
Please answer the following questions using this scale: 1=Always 2=Mostly 3=Sometimes 4=Seldom 5=Never
This Applicant:
Is able to direct and influence others along definite lines of action 1 2 3 4 5
Works well with associates and other group members 1 2 3 4 5
Is responsible 1 2 3 4 5
Puts principles and convictions into action 1 2 3 4 5
Knows how to control his/her emotions 1 2 3 4 5
Is honest and trustworthy 1 2 3 4 5
Would you be willing to have your child under the applicant’s supervision? Yes No
Describe the type of people with whom the applicant usually associates___________________________________
________________________________________________________________________________________________
How does this person react in situations of stress? ____________________________________________________
________________________________________________________________________________________________
Have you seen this person in a leadership role within your church? Yes No
If yes, please specify_______________________________________________________________________________
How long have you known the applicant?_____________________________________________________________
To your knowledge, is this applicant involved in drugs or alcohol? Yes No
If yes, please explain______________________________________________________________________________
Are you aware of anything about this person’s life that should preclude their working with children? Yes No
If yes, please state directly your concerns: ____________________________________________________________
________________________________________________________________________________________________
To the best of your knowledge, is the applicant’s physical condition able to endure an active week of camp as a participating volunteer?
Yes No
If no, please specify_______________________________________________________________________________
I recommend this applicant as a volunteer for Northwest District Summer Camps Yes No
Evaluation Completed By:
Name: ____________________________________________ Position: _____________________________________
Church: ___________________________________________ Phone: ______________________________________

District Volunteer Background Check
PO Box 1439, Bothell, WA 98041-1439
For Kids Camp contact: Susie Horn - 425.488.2500 x311 susieh@eastsidechurch.org
For Youth Camps contact: April Nault – 425.448.2500 x227 apriln@eastsidechurch.org
Every adult, including church staff members and pastors, who will be at Summer Camp must have a valid
background check on file with the Northwest District.
Applicant’s Name: ______________________________________________________________________________
Applicant’s Church: _______________________________________________City: _________________________
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Camp:  HS Camp, August 9 – 14  JH Camp, August 16 – 21  Kids’ Camp, August 23 – 28
Please check one box below:
 I have already volunteered (in that last 3 years) at a District camp or event and should have a background check on file with the
District.
 I do not have a current background check on file.
(please complete the background check form)

Background Check Release of Information Foursquare District Rep: Betsey
Request for Investigative Consumer Report and Conviction/Criminal History Record
Name:
(Please Print Clearly) (First) (Middle) (Last)
Social Security Number: Sex: M F Race:
Date of Birth: / / Place of Birth:
(Month/Day/Year) (County and State, or Country if outside the USA)
Driver’s License #: State: Home Phone:
Other names used and dates of use (including maiden name):
1. Name: from / to /
2. Name: from / to /
Have you ever been convicted of a crime? Yes No If yes, give details (date,
crime, location):
Current address: How long?
Number Street Apartment # City State Zip Code
Previous address: Dates: / to /
Number Street Apartment # City State Zip Code From (Mo/Yr) To (Mo/Yr)
If applicable, list all other addresses for the past ten years, starting with the most recent. Be sure to include city, state and
county, and the dates you resided there.
Address City State County From -- To
/ to /
/ to /
/ to /
/ to /
/ to /
/ to /
/ to /
Signature below authorizes and requests any present or former employer, school, police department, financial institution, division of motor vehicles, or other persons
or agencies having personal knowledge about me to furnish bearer with any and all information in their possession regarding me. I give permission that a photocopy
of this authorization be accepted with the same authority as the original. The above information is true to the best of my knowledge.
Signature Date
FOR OFFICE USE ONLY:
SEATTLE DISTRICT SUMMER CAMP: _____ HIGH SCHOOL _____ JUNIOR HIGH _____ KIDS’