Staff Application

Name *

First Name

Last Name

Birth Date *

MM

DD

YYYY

Biological Gender *

Male

Female

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you ever been a camper at Fusion?

Yes

No

Which areas of camp are you interested in helping with? *

Counselor

Field games

Kitchen

Photography

Crafts

Camp maintenance

Worship

First Aid

If you selected Counseling as a preferred area of camp, which age groups would you prefer to counsel?

11-12

13

14

15-16

Emergency Contact Phone *

(###)

###

####

Emergency Contact Phone - Secondary

(###)

###

####

Date of most recent Tetanus shot

MM

DD

YYYY

Physician Phone Number

(###)

###

####

Permission for medical care *

I hereby give Fusion staff permission to assume responsibility for securing necessary medical care for my well being as long as I am a participant of Fusion. In case of sudden medical emergency, I give the Fusion staff permission to secure any needed medical or surgical care. I understand that Fusion and its staff are not responsible for any medical expenses incurred.

I Agree

Have you ever been charged with or convicted of a crime or felony (other than minor traffic violations)? *

Yes

No

If applicable, please list your the date of your most recent PA Child Abuse History Clearance

You must bring a copy of your most recent clearance to camp before you can participate

MM

DD

YYYY

If applicable, please list your the date of your most recent PA State Police Criminal Records Check

You must bring a copy of your most recent clearance to camp before you can participate

MM

DD

YYYY

I give Fusion permission to exchange information with my pastor and/or any other references which I list regarding my ability to serve at Fusion.

Pastor's Name

First Name

Last Name

Pastor's Office Number

(###)

###

####

Reference #2 Name

First Name

Last Name

Reference #2 Phone

(###)

###

####

Reference #3 Name

First Name

Last Name

Reference #3 Phone

(###)

###

####