Returning Staff Registration Packet Forms

PLEASE COMPLETE, SIGN, AND RETURN THESE FORMS BY June 9, 2024

All fields with a green * are required.

It is recommended that you submit the form via computer or tablet. Some are having difficulties using a smart phone.

Step 1 of 3

NOTICE: While filling out these forms for Camp Areté you will be required to upload images/PDFs of your medical and prescription drug insurance cards, as well as your driver's license. Please have these images/PDFs available on your computer before you begin the registration process. If you have difficulty in securing images of these items, please contact the Camp Registrar.
Camp Agape Release
Camp Areté will take place at Camp Agape in Benton, TN. Camp Agape has its own informed consent and release requirements, which must be received by Camp Agape 30 days ahead of camp. This is a separate requirement from Camp Areté’s forms. Please be respectful of our new host’s rules and return (if you haven’t already) as soon as possible!

Camp Agape Participation, Media, and Medical Consent Form - 2024
I,
*
First Name Last Name
a
Gender*
Gender
am informed of the trip and activities offered by Camp Areté at Camp Agape in Benton, TN, beginning on Sunday, July 14, 2024 and ending on Saturday, July 20, 2024. I understand some activities (including but not limited to eating, outdoor activities, swimming, canoeing, hiking, and team building activities) involve a certain degree of risk that could result in injury or death. I have carefully considered the risk involved and hereby agree to attend and participate in all activities provided by Camp Agape. I hereby release and discharge Camp Agape and the Polk County Baptist Association, and their employees and volunteers from any liability, legal actions or claims which I or my family have, or might have, for any damage, injury or loss with respect to all activities associated with Camp Agape as well as their heirs, executors, administrators, successors, or assigns, from any cause of action of any nature whatsoever arising from my participation in any and all activities associated with Camp Agape.

Furthermore, I agree that this agreement is deemed to be entered into in the State of Tennessee and to be governed and enforced pursuant to Tennessee law. I submit to the exclusive jurisdiction of any court of the State of Tennessee located in the County of Polk for the purpose of any dispute. I agree that in any event that I or my family take any legal action against Camp Agape or the Polk County Baptist Association, or their employees and volunteers, which is decided in favor of Camp Agape or the Polk County Baptist Association, or their employees and volunteers, I will be responsible for all legal fees, court costs and out-of-pocket expenses of Camp Agape and the Polk County Baptist Association, and their employees and volunteers.

To promote, evaluate, or otherwise describe Camp Agape’s programs and activities, I give permission to Camp Agape and its agents, to use in connection with any publication (including but not limited to brochures, booklets, videos, reports, press releases, Web sites, and exhibits) any image or recording in which I appear, to use and cite any comment(s), verbal or written, made by me about the program, and to use my name in connection with any publication and in such manner as determined by Camp Agape.

I hereby state that I am in good, normal health and have no abnormal physical, emotional or mental handicaps except as listed below. I accept financial responsibility for my own well-being and hereby grant authority without limitation to the church/group sponsor, Camp Agape Director, employees, volunteers and agents in all medical matters to obtain medical attention, hospitalize, treat, and order injections, anesthesia, surgery in case of sickness or injury to myself. I also authorize the attending physician to provide any needed medical treatment. I also understand that it is my responsibility for advising/providing to church/group sponsor, Camp Agape Director, employees, volunteers and agents information/instructions for all pre-existing medical conditions and/or physical, emotional, or mental handicaps.

I, the undersigned, have read, understand and accept all of the terms and conditions set forth in this agreement. I do hereby verify that the information provided is correct, and I do hereby release and forever discharge all sponsors, Camp Agape and Polk County Baptist Association from any and all claims, demands, actions or cause of action, past, present, or future arising out of any damage or injury or death or loss of property while participating in Camp Agape. Also, I understand that a copy of this form is as valid as the original. In the event of an accident, injury, or illness while I am participating with Camp Agape my personal insurance or church’s insurance is the primary insurance carrier. Camp Agape’s liability insurance is secondary.
Signature*
Date*
MM slash DD slash YYYY
Email*
Enter Email Confirm Email

Staff Information
Birthdate*
MM slash DD slash YYYY
Age*
T-shirt size*
Staff position desired*
- Girls' Counselor
- Boys' Counselor
- Crafts Leader
- Servant Leader
- Other
Home phone*
Cell phone*
Home address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Emergency contact information
Emergency contact information*
First Last
Relationship to staff member*
Contact's phone*
Please indicate*
Medical and insurance information
Family physician name*
First Last
Family physician phone number*
Has your insurance information changed from last year?*
Name of insurance policy holder*
Full name
Policy holder's date of birth*
MM slash DD slash YYYY
Name of insurance carrier*
Carrier phone number*
Group number*
Policy number*
Billing address*

Complete insurance carrier billing address
Prescription plan provider*
Prescription plan number*
Prescription plan phone number*
List food allergies
List insect allergies
Require Epipen?*
Other allergies, current medications, and/or medical conditions
Please scan or take a picture of the insured party’s driver’s license, health insurance card and prescription plan identification card. Please include scans or photos of the FRONT and BACK of the insurance and prescription cards. Use the File Upload button below to upload those images or PDFs with this form.
Upload files for insurance cards (front & back), prescription plan cards (front & back), and driver's license*
Drop files here or

Accepted file types: jpg, png, pdf, tif, jpeg, Max. file size: 512 MB.

Informed Consent
Please read the following statements carefully so that you are fully aware of the consent you are giving to Camp Areté and sign in the signature box below.
- Consent to attend: The health history is correct and complete to the best of my knowledge. The person herein named has permission to engage in all camp activities except as noted. I understand that part of the camp experience involves activities and group living arrangements and interactions that may be new to me, and that they come with certain risks and uncertainties beyond what I may be used to dealing with at home. I am aware of these risks, and I am assuming them. I realize that no environment is risk-free, and so I have familiarized myself with the camp rules and standard operating procedures, and I understand the necessity of following them.
- Meal consents: I understand that it is my responsibility to manage my own food avoidances with available menu choices. Camp Areté is unable to store special ingredients or prepare special meals. Camp Areté is entirely incapable of accommodating allergies to corn or soy. Exceptions will be made at the discretion of the kitchen director in consideration for camp staff and other campers.
- Consent to release medical records: I agree to release any records necessary for treatment, referral, billing, or insurance purposes.
- Consent to release medical information to camp staff: It is my intention that the appropriate representatives of the camp be treated as personal representatives for the purposes of disclosing protected health information pursuant to the privacy regulations promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996. I hereby agree (pursuant to 45 CFR 164.510(b)) to the disclosure to camp representatives of the protected health information of the person herein described, as necessary to provide relevant information to the camp representatives related to my ability to participate in camp activities. This authorizes all associated medical staff, including EMTs, nurses, physician’s assistants, and medical doctors to release information concerning my medical status, medical condition, injuries, prognosis, and diagnosis and related personally identifiable health information to camp staff. This information includes injuries or illnesses relevant to participation in the above-named camp.
  The reason for this disclosure is to advise camp staff of the nature, diagnosis, prognosis or treatment concerning any medical condition and any injuries or illnesses the camp participant may have so that good decisions can be made regarding the participant’s ability and suitability to participate in camp activities. I understand that the entities that receive the information are not health care providers or health plans covered by federal privacy regulations, and that the information described above may be re-disclosed publicly and that the information will no longer be protected by those regulations.
  I understand that I may revoke this authorization in writing at any time by notifying Camp Areté, but if I do, it will not have any effect on actions Camp Areté took in reliance on this authorization prior to receiving the revocation. This consent expires one year from the date it is signed.
  This completed form may be photocopied for trips out of camp.
- Hold harmless: The undersigned does hereby agree to hold harmless the camp, its staff and program leaders, and associated churches in the event of injury or accident.
- Media release:Those who prefer that their names or pictures not appear on the Camp Areté blog or the website should indicate that preference by marking the “opt out” box below. I understand that if I opt out of media, Camp Areté is unable to remove my image from any video used in media.
- Staff member opts out of his/her name and/or photo on the Camp Areté website or blog.
Video disclaimer*
- Notice: If you appear in a video taken during camp, we are not able to edit you out from the video.
Staff signature*
Date*
MM slash DD slash YYYY
Email
This field is for validation purposes and should be left unchanged.

Exciting Opportunity for 2024!

Returning Staff Registration Packet Forms

Step 1 of 3

Camp Agape Release

Staff Information

Emergency contact information

Medical and insurance information

Informed Consent

About Camp Areté

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