Camp Kum-Ba-Yah Volunteer Application

CONTACT INFORMATION

First Name *

Last Name *

Current Address *

City *

State *

Zip Code *

Phone *

Email Address *

Permanent Address (if different from current) *

City *

State *

Zip Code *

Best Time to Contact *

Have you previously done volunteer work for this organization? *

Yes

No

REFERENCES

Name *

Address *

Phone *

Relationship *

Name *

Address *

Phone *

Relationship *

ALLERGIES HEALTH CONDITIONS

Please share with us any allergies or health conditions that may affect your volunteer service or that the camp should be aware of. *

Do you have current First Aid Certification? *

YES

NO

Do you have current CPR Certification? *

YES

NO

Would you be interested in obtaining these certifications? *

YES

NO

EMERGENCY CONTACTS
Please list two people we may contact on your behalf in the case of an emergency.

Name *

Address *

Phone *

Relationship *

Name *

Address *

Phone *

Relationship *

INTERESTS
Please share with us your volunteer interests and expertise as well as any hobbies you enjoy. *

TB TEST
If you will be working with the children who attend Camp Kum-Ba-Yah, we require that you provide us with the negative results of your most recent TB test, no more than 2 years old. Are you willing to provide us with these results? *

YES

NO

CRIMINAL RECORD CHECK
Have you ever been convicted of a crime other than a minor traffic violation? Please explain.
*

NOTE: All Camp Kum-Ba-Yah volunteers and staff must sign a Voluntary Disclosure Statement as well as have a criminal background check preformed. These forms will be provided to you by the camp Staff and should be returned within a reasonable amount of time.

Unconditional Release and Waiver
In consideration for the permission to enter the property of Camp Kum-Ba-Yah, Lynchburg Covenant Fellowship and Church of the Covenant, the undersigned is herby on notice of the inherent dangers and risks of injury from the natural vegetation and habitat, topography, and wildlife present on said grounds. The undersigned is informed that these grounds are home to campgrounds located in natural woodland domicile with playgrounds, campsites, picnic tables, trails, gently flowing creeks and a natural lake which present natural hazards, obstacles and wildlife which can include but is not limited to, snakes, bees, spiders, birds, lizards, deer, moles, mice, bears, foxes, raccoons, ticks, fleas, chiggers, and poison ivy.

This notice and release is understood to release the aforesaid not only for the act of omissions of individuals, but also for the physical conditions of the aforesaid premises and the equipment used therein.

Name of Participant *

Name of Participant or Guardian if Participant is under 18 years *

Signature of Participant or Guardian *

Date *