2024 Student Camp Intern Application

Students ages 15 to 20 years old qualify as student workers for Kid's camp and Jr. High camp. A payment of $50 dollars for working one camp, or $100 for both, is required (food and lodging cost). Limited spots available.

Parents / Guardians must fill out the form, unless worker is over the age of 18 years as of July 1st, 2023.

Name Name First Last
Camp(s) Working

Camp(s) Working Elementary (Elementary (Grades 1st - 4th | June 26 - June 29) Junior High (Grades 5th -8th | August 5 - 9) High School (Grades 9th - to age 19 | July 15 - July 19)
Would you like a T-Shirt? $20 Additional fee (unless you are planning on on being a camper AND you pre registered)
Shirt Size
Email
Gender
Social Security (background checks required if 18 years or older)
Birthdate Birthdate / MM / DD YYYY
Phone Phone - ### - ### ####
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Drivers License (18+ years for background checks)
State Issued
Home Church
Pastor Pastor First Last
Are you interested in being an assistant counselor?
Emergency Contact
Name Name First Last
Emergency Contact Phone Emergency Contact Phone - ### - ### ####
COVID-19 Release

The novel Coronavirus, COVID-19, has been declared a world-wide pandemic by the World Health Organization.
By participating in programs, services, and activities of Impact MI, PCG, Michigan District PCG, you agree to the following:

On behalf of yourself and your children, you hereby release, covenant not to sue, discharge, and hold harmless Impact MI, PCG, Michigan District PCG, it's emplloyees, agents, and representatives, of and from all liabilities, claims, actions, damages, costs or expanses of any kind arising out of or relating to your participation in our programs, services, or activities. You understand and agree that this release includes and claims based on the actions, omissions, or negligence of this organization, it's employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any such programs, service, or activity.
Name Name First Last
Date Date / MM / DD YYYY
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Please include the names of any minor family member (if any)
COVID-10 PPE

Please be advised that masks will be available to anyone wishing to wear one. Hand sanitizing stations will be available throughout our campus, as well as disinfecting wipes. Regularly schedules disinfecting procedures will be conducted by our staff and volunteers.
Health Form
Name of Health Insurance
Policy Number
Phone Phone - ### - ### ####
Questionnaire
Are you currently a Christ follower?
If so, how long have you followed Christ?
Have you ever worked at an Impact MI camp?
Do you use narcotics, hallucinogens, tobacco, or drink alcohol?
Do you approve of or practice Homosexuality/sexual perversion?
Do you approve or practice any form of occult?
Have you ever been charged or convicted of child abuse or a crime involving actual or attempted sexual molestation of a minor?
Do you have any outstanding warrants or restraining orders?
Have you ever been convicted of a felony?
BY SIGNING MY NAME AND SUBMITTING BELOW:

I state that I have carefully read this forgoing release and know that contents the contents thereof. By signing below I release as my own free will, as this is a legally binding agreement that I have read and understand.

I also vow to give my best effort for the duration of the time I am serving at Impact MI Camps. I will help out wherever needed, because I am here to serve. I realize by serving at Impact MI Camps I have the opportunity to help shape and mold a life. I am making a commitment to myself, Impact MI Staff, and the campers to be a role model and an example of Christ's love. I agree to abide by all camp rules/regulations and to cooperate with the Camp Director(s) and all Staff.

If you are single: Furthermore, understanding the hindrance courtship imposes, I will abstain from camper(s), Camp Director(s) and Staff.

I also, hearby waive any & all claim against the Pentecostal Church of God Michigan District, Inc. or it's agents, because of injury or damage that may be incurred to myself and/or my property in connection with/or an incident & activity of youth camp. I understand that secondary insurance is provided and that I am am covered by primary insurance. I also understand that I may be photographed or video recorded for camp DVD, video, skits, & live events. This footage/photos may also be used for future reference, not limited to but including video promotions, still shots, & the internet.
Name Name First Last
I have read and agree to the rules of Impact MI Summer Youth Camps as stated on www.impactmi.org

I have read and agree to the rules of Impact MI Summer Youth Camps as stated on www.impactmi.org Check Yes Here
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

2024 Student Camp Intern Application

2024 Student Camp Intern Application

Emergency Contact

COVID-19 Release

COVID-10 PPE

Health Form

Questionnaire

BY SIGNING MY NAME AND SUBMITTING BELOW: