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Junior Counselor Registration
2022 Junior Counselor Form
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Home Phone
*
Work/Cell Phone
*
Email
Date of Birth
Month
Day
Year
Grade Completed
Areas to Serve
Junior Staff must be at least 12 years old and entering 8th grade by the start of Camp.
First Choice
*
Please indicate your first choice of activity.
Basketball (with children ages 8-12, please bring a basketball)
Cheerleading (with children ages 6-12)
Soccer (with children ages 6-12, please bring a ball & shin guards)
Arts & Crafts (with children ages 6-12)
Flag Football (with children ages 6-12)
Team 45 (with children ages 4-5)
Childcare (with children under age 4)
Second Choice
*
Please indicate your second choice of activity.
Basketball (with children ages 8-12, please bring a basketball)
Cheerleading (with children ages 6-12)
Soccer (with children ages 6-12, please bring a ball & shin guards)
Arts & Crafts (with children ages 6-12)
Flag Football (with children ages 6-12)
Team 45 (with children ages 4-5)
Childcare (with children under age 4)
Third Choice
*
Please indicate your third choice of activity.
Basketball (with children ages 8-12, please bring a basketball)
Cheerleading (with children ages 6-12)
Soccer (with children ages 6-12, please bring a ball & shin guards)
Arts & Crafts (with children ages 6-12)
Flag Football (with children ages 6-12)
Team 45 (with children ages 4-5)
Childcare (with children under age 4)
T-shirt Size
*
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult X-Large
Health & Permission
Allergies
*
If none, write "none."
Health Issues
*
If none, write "none."
Medical and Liability Release
We realize that no activity is without the possibility of unforeseen hazards which could result in injury to an individual. As a parent or guardian, it is your responsibility to instruct your child as to the importance of their conduct, which will help to ensure that they have a safe and enjoyable time while participating in this activity. By electronically signing this form, you, as a parent, guardian, or other responsible party, agree to assume the risks and hazards which are inherent in this kind of activity. You also agree to abxolve and hold harmless the sponsoring organizations and their representatives for damage, loss or injuries to the child for whom you sign. I hereby give my child permission to participate in this activity and give my permission to the leaders of this Sports and Art Camp to authorize any treatment deemed necessary by medical personnel in the event of accident or illness during this activity. I further give my permission for the use of any photos or likeness of my child by the sponsoring organization for their use in promotional materials.
Signature of Parent/Guardian
*
Printed Name of Parent/Guardian
*
First
Last
Emergency Contact Information
Should the parent or guardian (primary contact) not be available, who should we contact (secondary contact) in case of an emergency?
Name
First
Last
Home Phone
Cell Phone
Work Phone
Δ