Microsoft word - new volunteer application_1997.doc

Make Promises Happen is a program of Central Christian Camp and Conference Center.
Please fill out the form COMPLETELY
First Name _________________________________________ Last Name____________________________________________________ Nickname ________________________________________________________ Sex _____ Age _____ Date of Birth _____/______/_____ Address __________________________________________________________________________________Apt. # _________________ City _______________________________________________ State______________ Zip____________________ Shirt Size __________ Home Phone _________________________ Alt. Phone_________________________ Email Address_____________________________ Previous volunteer experience? ______________________________________________________________________________________ Have you attended MPH counselor training? ___________________________________________________________________________ How did you hear about MPH? ______________________________________________________________________________________ Why do you want to be a volunteer counselor?__________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Have you ever been convicted of a felony or misdemeanor excluding traffic violations? Yes/No If yes please explain. (A yes answer will not automatically exclude you from consideration.) ____________________________________ _______________________________________________________________________________________________________________ Do you consent to authorize Make Promises Happen to conduct a criminal background investigation?
Social Security number (required) _______________________ Signature of volunteer ________________________Date______________ Signature of guardian (if volunteer is under the age of 18) ______________________________________________ Date______________ EMERGENCY CONTACT INFORMATION:
Parent/caregiver_____________________________________________________________ Relationship___________________________ Address ________________________________________________________________________________________________________ Home Phone __________________________ Cell Phone_________________________ E-mail __________________________________ 2nd Parent/caregiver__________________________________________________________ Relationship___________________________ Address ________________________________________________________________________________________________________ Home Phone __________________________ Cell Phone_________________________ E-mail __________________________________ If in the case of emergency, the parent cannot be reached, we ask that you give 2 additional names and numbers that we might
contact. (pager and/or cellular phone numbers are acceptable)
Name __________________________________________________ Phone Number __________________ Relationship ______________ Name __________________________________________________ Phone Number __________________ Relationship ______________ Please visit our website at MEDICAL AND HEALTH CARE:
Are you allergic to Penicillin? YES____ NO____ Date of last Tetanus vaccination: ___________________ Have you been under the doctor’s care in the last 12 months? If yes, please explain. ______________________________________________________________________________________________ Are there restrictions on exercise? YES____ NO____ If yes, please explain. ______________________________________________________________________________________________ Do you have any allergies to medications and/or food(s)? YES____NO____ If yes, please list __________________________________________________________________________________________________ AS NEEDED MEDICATIONS: Please mark X on the medications below you are NOT allowed to take if needed.
For Pain, Fever, anti-inflammatory:

__ Acetaminophen (Tylenol) __ Ibuprofen (Motrin, Advil) __ Naproxen (Aleve) For allergic reactions, sleep aide, motion sickness, nausea:
__ Diphenhydramine Hydrochloride (Benadryl) For upset stomach, diarrhea:
For heart burn:
Topical Creams
Central Christian Camp and Conference Center’s Make Promises Happen camping program hereinafter referred to as the “Camp” requires a signature for all attendees of the Camp and participants of the Camp activities. I hereby give permission for the volunteer listed on this application to attend and to take part in all Camp activities. Also, I give permission to the Camp to provide routine health care, administer prescribed medication and to seek emergency medical treatment for the volunteer listed on this application. _______________________________________________________________________________________________________________ Signature or Signature of Parent or Legal Guardian PHOTO CONSENT:
MPH regularly photographs and films our camp for fundraising and publicity purposes. The following consent form allows MPH to use your (your child’s) photograph or film for these purposes. In consideration of Make Promises Happen permitting me (my child, who is under 18 years of age) to attend MPH camp, I hereby give my consent to MPH to use my (my child’s) name, picture, likeness, writings, biographical information, audio tape and/or videotape recordings and sound and/or silent motion pictures of me (my child) in any medium for editorial, educational, promotional and advertising purposes, for the solicitation of contributions and for any other purpose in the furtherance of the corporate purposes and objectives of MPH. ________________________________________________________________________________________________________________ Signature or Signature of Parent or Legal Guardian ****************************************************************************************************************
Please include a photograph of yourself and return this application to: Make Promises Happen, #1 Twin Cedar Lane, Guthrie OK 73044 Please visit our website at


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