2024 Jr Youth Camp WORKER Application

Legal Name

Address (no PO Box can be used due to background check requirements)

Phone

This address will receive a confirmation email

Gender

All workers must be 21 years old at the start of Youth Camp to be approved!

Date of Birth: (MM/DD/YY)

Age

Married?

Social Security Number:

Driver's License Number:

State where license was issued:

Any injury or sickness preventing you from participating in camp activities or which the Executive Staff should be aware?

Yes No

If yes, please explain:

Have you ever required any psychiatric treatment, counseling, or hospitalization?

Yes No

If yes, please explain:

List all current prescription and OTC meds:

Are your immunizations up to date?:

Yes No

List any allergies or food modifications:

Emergency Contact's Name:

Emergency Contact's Best Phone Number:

Relationship to emergency contact:

Family Physician:

Family Physician Phone Number:

Insurance Carrier:

Insurance Phone Number:

Policy or Group #:

Housing Request:

UPCI Licensed Pastor's Name: (this name is used for dorm placement purposes for deans and matrons. If you attend a church with a Senior Pastor/Bishop/Assistant Pastor, all women/men from the same church need to use the same pastor's name.

Official Name of Church:

City where your Church is located:

Each Dean/Matron is allowed to name ONE other Dean/Matron they would like to stay in the dorm with. Please note that every effort is made to place all Workers from the same church together in the same dorm (separated into males and females).

Job request will be honored based upon availability. However, I understand Youth Ministry has the right to change my job position as needed to facilitate the success of Youth Camp.

T-Shirt Size

Complementary Registration is reserved only for TXYM Committee, Paid Camp Staff, and those approved ONLY by Bro. Williams

Payment(including t-shirt, concession card, and background check fee):

I, the undersigned, affirm the information contained in this application is complete and correct to the best of my knowledge. I authorize the Texas District United Pentecostal Church (TXDUPC) and/or its agents to make a thorough, independent investigation of my background, references, character, fitness for work, criminal or police records, including those maintained by both public and private organizations and all public records for the purpose of confirming information contained on my application and/or obtaining other information which may be relevant to my qualifications for Camp work. I release the TXDUPC and/or its agents and any person or entity (named or unnamed in this document) which provides information pursuant to this authorization, from any and all liabilities, claims, or lawsuits from me, my heirs or family in regards to the information obtained from any and all of the above referenced sources excepting only in the communication of knowingly false information. Furthermore, I authorize the Camp Nurse and/or Executive Staff to make emergency medical decisions on my behalf as required by law. I understand the TXDUPC will not be responsible for medical expenses incurred solely on the basis of this authorization. Should my application be accepted, I agree to be bound by all Bylaws and Camp Guidelines/Policies of the TXDUPC, fulfill my job description given by the Executive Staff, and refrain from unscriptural conduct in the performance of my services on behalf of the TXDUPC. This is a legally binding release I have carefully read and know the contents thereof, and I sign this release as my own free act.

Yes No

Electronic Signature

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

2024 Jr Youth Camp WORKER Application

Description

Please Fix the Following