Breakaway Teen Camp 2019
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Camper Personal Information
First Name *
Middle name *
Last name *
Preferred name
Birth date *
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Gender *
Grade (Grade completed during 2018-2019) *
Address 1 *
Postal code *
City *
State *
Home phone (Use cell phone if you don't have one)
Cell phone *
Work phone (Not required)
Email address *
Select program type *
Parent / Guardian 1
First name *
Last name *
Gender *
Martial status *
Relationship status *
Employer (optional)
Camper lives with contact? *
Release camper to contact? *
Address 1 *
Postal code *
City *
State *
Home phone (Use cell phone if you dont have a home phone)
Cell phone *
Email address *
Parent / Guardian 2
First name
Gender
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Marital status
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Relationship to student
Occupation
Employer
Camper lives with the contact?
Clear selection
Release camper to contact?
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Address 1
Postal code
City
State
Home phone
Cell phone
Email address
Emergency contact
First name *
Last name *
Gender *
Martial status *
Relationship to student *
Occupation (optional)
Employer (optional)
Camper lives with the contact? *
Release camper to contact? *
Address 1 *
Postal code *
City *
State *
Home phone (use cell phone if you dont have one)
Cell phone *
Email address *
Camper Profile Sheet
I am the parent/guardian of this student being registered for camp *
Church city / Church name
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Leaders name
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Is there any information we should have regarding the welfare of this camper? (disabilities, restrictions, etc?) *
Disclaimer and acknowledgement (Parent / guardian signature) *
I do hereby state that I have legal custody of this child, a minor, who resides with me. While this minor is a registered ca,per at any Illinois assemblies of God summer camp, I hereby authorize any director, counselor, nurse, dean, lifeguard, or other responsible person of said camp to consent to any x-ray, examination, anesthetic, medical, or surgical treatment, and hospital care, to be rendered to this minor under the general or special supervision and on the advice of any physician or surgeon licensed to practice in the united states, when such medical or surgical treatment is necessary. I also give permission for my child to receive over-the-counter medication from the camp nurse if necessary.We give full permission to the Illinois assemblies of God summer camps to reproduce any photograph and/or video image of me/my student for promotional usage without obligation to me/my student. We have read these rules and agree to abide by them and do hereby give permission to participate in all camp activities *By typing my signature, this holds the same legal value as a handwritten signature
Todays date *
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Student acknowledgement (Student signature) *
Regulations are given as guidelines for every camper to follow. This code of conduct, which can be found on the ISM camp webpage, has been established for your protection and the benefit of every person present. The lack of cooperation, unnecessary roughness, lack of respect for property or an unwholesome attitude on the part of any camper will result in expulsion from the camp. The expense of transporting the expelled camper(s) home is the responsibility of the parent/guardian
Today's date *
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Support staff profile sheet
By clicking Yes I acknowledge that I am 18 years or older. By clicking no, I recognize that I will need a parent or guardian to sign off on this form
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I am the youth pastor/main youth leader at my church
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I have past experience as an EMT or nurse and would be willing to help in this area
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I am willing to be a counselor if that is where the greater need it
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I have previously served at Illinois youth camps
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If yes, how many years
I have been born again and know my salvation is real
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Do you currently use tobacco, alcohol or any illegal drugs
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In the past, have you used any illegal drugs
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If yes, how long ago?
Was it prior to salvation?
Clear selection
During the past 10 years, have you ever been convicted of a crime, excluding traffic violations (speeding tickets)
Clear selection
If yes, please explain
Have you been involved with or convicted of child abuse or a crime involving actual or attempted sexual molestation of a minor?
Clear selection
If yes, please explain
In one word, describe your health with 1 being great and 5 being poor
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Within the last year, have you had problems with nervous breakdowns, extreme depression, extreme anxiety, attempted suicide, or destructive temper?
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Insurance carrier *
Coverage start date *
MM
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DD
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Coverage end date
MM
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DD
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Insurance co phone number
Insured's name (first, last)
Insurance number
Group policy number
Do you have allergies?
Clear selection
If yes, please explain
Please list the year you received the following immunizations (if you have not received these, please place zeros in the date box
Dipotheria
MM
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Whooping cough
MM
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Polio
MM
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DD
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Tetanus toxid
MM
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DD
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Do you have
Is there any information we should know about regarding your welfare (handicaps, restrictions, diets, etc?)
Reference
Please have your pastor fill out the pastoral reference form. You can do so by going to

https://form.jotform.com/90495779739985.

This will open a link in a new window; copy and paste the link to send to your pastor. This link will also be available on the camp page of our ilsmonline.org website if you would like to point your pastor there directly.

You will also need a personal reference to fill out on your behalf. Go to here for the personal reference:

https://form.jotform.com/90495779739985

This link will also be available on the camp page of our ilsmonline.org website if you would like to point your reference there directly.

Disclaimer and Acknowledgement:

I acknowledge that I am at least 18 years of age and if I am not, I have my parent/guardian here to sign for me. I do hereby state that while I am registered staff member at any Illinois assemblies of God summer camps, I hereby authorize any director, counselor, nurse, dean, lifeguard, or other responsible person of said camp to consent to any x-ray, examination, anesthetic, medical or surgical treatment, and hospital care to be rendered under the general or special supervision and on the advice of any physician or surgeon licensed to practice in the united states, when such medical or to reproduce any photograph and/or video image of me for promotional usage without obligation to me. I have read the rules and agree to abide by them

Applicant signature
Background investigation consent
By clicking yes, I acknowledge that I am 18 years or older. By clicking no, I recognize that I am under 18 years old and a background check will not be ran. If no, still fill out the remainder of the form, sign and date
Clear selection
Drivers license number
Drivers license state
Disclaimer
I hereby authorize illinois student ministries/and/or its agents to make an independent investigation of my background, references, character, past employment, education, criminal or police records, including those maintained by both public and private organizations and all public records for confirming the information contained on my application and/or obtaining other information which may be material to my qualifications for volunteering for counselor/staff at the illinois summer camps

I release illinois student ministries and/or its agents and any person or entity, which provides information pursuant to this authorization, from any and all liabilities, claims or law suits in regards to the information obtained from any and all of the referenced sources used.

The information on these forms is my true and legal name and all information is true and correct to the best of my knowledge

*This typed signature holds the same legal value as a handwriten one
Applicant signature
Camp Test
The camp counselor/support staff test must be completed in order to be eligble to help with the ISM breakaway summer camp *please reference the camp manual available for download on the ISM website (www.ismonline.org)


CAMP MANUAL: http://ilsmonline.org/wp-content/uploads/2016/04/Camp-Manual-2016.pdf


The purpose of the ISM camping program is to encourage the development of the whole camper:
It is OK to give a camper an aspirin if they only have a headache
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If everyone in the room agrees to have a pillow fight then, and only then, is it permissible to do so
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Counselors are allowed to leave the grounds if they have someone to watch and be responsible for their campers
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Support staff are allow to leave the grounds if they have someone to cover their duties
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Campers must attend all scheduled activites. They cannot stay in the room themselves
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Regardless of the severity of the sickness, accident or injury the camp nurse should be consulted immediately to access said sickness, accident or injury
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Is it OK to let someone who is not assigned to your room to stay in your room if you have an extra bed
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I can give my room key to a camper if they forget something
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When vacating the room I should; be the last one to leave, lock the door and window, and turn out the light, everytime
Clear selection
Fireworks, smoking, alcholic beverages, and/or drugs are NOT allowed in the campgrounds. Is this correct?
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The counselor and support staff are the keys to a successful camp
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Campers should never go to the nurse after lights out without a staff member
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If a student asks you to promise not to tell anyone about sexual abuse or attempted suicide, you should not honor their wishes
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Taking pictures and videos inside the room is OK as long as everyone is fully clothed
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Color wristbands are optional, campers do not have to wear them
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Campers must bring all medication to the camp nurse
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AS a counselor, you are allowed to meet with friends after your campers are asleep
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Counselors and staff do not need to wear their lanyard badge during the evening service
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The best way to talk with a student about a serious matter is to set aside a time when you can be alone with them in the room
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I am finished with this camp test
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Medications
Are you bringing any medications to camp?
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Medication Name
Strength
Route
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Quantity per Dose
Dosage
Reason
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Comments
Add a schedule for what days / times the student needs this medication
Over the counter Medications
The following over-the-counter medications may be given to my camper
Comments (Special instructions or allergic reactions)
Medication list 2
Medication name
Strength
Route
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Quantity per Dose
Dosage
Reason
Comments
Add a schedule for what days / times the student needs this medication
Over the counter Medications
The following over-the-counter medications may be given to my camper
Comments (Special instructions or allergic reactions)
Medications list 3
Medication name
Strength
Route
Clear selection
Quantity per Dose
Dosage
Reason
Comments
Add a schedule for what days / times the student needs this medication
T Shirt
Size / Price
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Lanyard Photo ID upload
Upload here: https://form.jotform.com/90595177551970
Submit
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