Valley Worship Center

Urban Camp 2013

Who is Our God
Children (ages 6-12)
Monday 8/12 at 10:00 AM to Tuesday 8/13 at 8:00 PM
Youth (ages 13-17)
Wednesday 8/14 at 12:00 PM Noon to Thursday 8/15 at 11:00 PM
At Brooktondale Nazarene Camp and Retreat Center
Brooktondale, New York

Counselor/ CIT (Counselor in Training) Packet

CIRCLE ONE OR BOTH:

CHILDREN

YOUTH

All applicants MUST COMPLETE AND SUBMIT the following forms by

Friday, August 9, 2013.
ABSOLUTLY NO EXCEPTIONS!

___ Application
____Rules Sheet (CITs ONLY)
____Medical Form
____Immunization Records
____Disclaimer Form (CITs ONLY)
____$10 deposit OR Completed Work Wavier Form (CITs ONLY)
____$35 payment per camp or $70 for both (Counselors ONLY)

Urban Camp 2013 Who is Our God?

Hosted at Brooktondale Campgrounds
120 White Church Rd. | Brooktondale, NY

Camp Director:
Pastor Clare Pietra (315) 492-2231
Return completed applications to the directors attention:
Valley Worship Center
2929 Midland Ave | Syracuse, NY 13205 | (315) 492-2231

Counselor & CIT (Counselor in Training) Application

CONFIDENTIAL
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Requirements for a counselor are as follows:

Age 21+ (applicants ages 18-20 please contact Camp Director prior to
submitting application)
Actively involved in your local church
Able to fully participate in the camp schedule
Display a lifestyle consistent with the beliefs & practices of the Christian Faith
Have a love for God and an expectancy that He will do great things in our
lives during Urban Camp.

Applicant Information
Full Name:
_________________________________________________________
Gender: M / F
Mailing Address: ________________________________ City/State/ZIP:
____________________
Home Phone: ____________________________
Cell Phone: _____________________________
DOB (M/D/YY): _____/_____/_____
Church: ___________________________________________
Social Security #: _______-______-_________
Email: ___________________________________
Medical Allergies/Issues of concern:
__________________________________________________
________________________________________________________________
Occupation:
________________________________________________________________
Emergency Contact
Name: ________________________ Phone: ___________________
Relationship: ____________

Personal Information
Have you personally accepted Jesus Christ as your Lord and Savior, and are you
committed to having the character of Jesus displayed in your life?
Circle Yes or No
Briefly describe your relationship with God right now.
________________________________________________________________
________________________________________________________________
________________________________________________________________
Why have you chosen to apply to be a camp counselor?
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Have you, at any time, been accused (rightly or wrongly) of sexual abuse,
maltreatment, or neglect?
Circle Yes (explain) or No
________________________________________________________________
________________________________________________________________
________________________________________________________________
Have you ever been accused or convicted of possession/sales of controlled
substances or of driving under the influence of alcohol or drugs?
Circle Yes (explain) or No
________________________________________________________________
________________________________________________________________
________________________________________________________________

Have you ever been arrested or convicted of any criminal act (aside from a traffic
violation)?
Circle Yes (explain) or No
________________________________________________________________
________________________________________________________________
________________________________________________________________
Have you been a victim of sexual or physical abuse?
Circle Yes (explain) or No
________________________________________________________________
________________________________________________________________
________________________________________________________________
What strengths do you bring to the leadership team at Upstate Teen Camp?
________________________________________________________________
________________________________________________________________
________________________________________________________________
What do you perceive are your weaknesses in regards to being a Teen Camp
counselor?
________________________________________________________________
________________________________________________________________
________________________________________________________________
Is there anything not already discussed, that you would like to share with the
Camp Director?
Circle Yes (explain) or No
________________________________________________________________
________________________________________________________________
________________________________________________________________

References
List three adults you have known for at least one year, who are not related to
you, and have a definite knowledge of your character and ability to work with
students.
1. Pastor/Youth Pastor of the church you are presently involved in:
Name: ___________________________________
Length of time known: ____________________
City/State: ____________________________
Work phone: _______________________________
Home/Cell phone: _________________________
Email: _________________________________
2. Employer, Fellow Employee, or Teacher:
Name: ___________________________________
Length of time known: ____________________
City/State: ____________________________
Work phone: _______________________________
Home/Cell phone: _________________________
Email: _________________________________
What is your relationship to this person? _______________________________
3. Friend:
Name: ___________________________________
Length of time known: ____________________
City/State: ____________________________
Work phone: _______________________________
Home/Cell phone: _________________________
Email: _________________________________
What is your relationship to this person? _______________________________

Signature
By submitting this completed application, I am committing to be a camp counselor (if
accepted) for the dates of Urban Camp 2013. Additionally, I understand I will be
responsible for the care and safety of adolescents ranging in age from 6-15. I have
completed this application to the best of my knowledge, and have provided truthful
information. I also give permission to the Upstate NY District NYI Council and Camp
Director(s) to contact my references and perform a criminal background check in
accordance with NYS Health Department regulations. I understand that all information
provided on this application is confidential and will only be used in reference to my status
as an Upstate NY District camp counselor/volunteer.

Signed: _________________________________________
Date: ___________________________
Applicants will be notified of their acceptance as a counselor.

IMPORTANT
Emergency Contact:
If at any time there is an emergency while we are at camp
and you need to contact your child, please call:
Camp Director Clare Pietra
(315) 480-0273
Brooktondale Nazarene Camp and Retreat Center:
(607) 539-7708

WHAT TO PACK
Clothing for 2 days
Pajamas
Pillow and blanket or sleeping bag (there are already mattresses in the
cabins)
Bathing suit (or something to get wet in)
Toiletries and a towel
(Optional) $5 spending money for the Snack Shack

Valley Worship Center

Urban Camp 2013
Our goal is to share the love of Christ with our community by providing a place for them
to experience God at a camp that is safe for everyone. In an effort to protect every
participant, we will enforce and expect compliance with the following rules of conduct:

Rules of Conduct
1. Participant must show respect to all counselors and workers at the program, as well as
other campers.
2. Participants must not go outside the designated areas of the campground.
3. No boys in girls dorms/ no girls in boys dorms under any circumstances.
4. No use of the restrooms without counselor permission.
5. Participant must not use vulgar language.
6. Participants must respect the property of the campgrounds by not littering,
vandalizing, or stealing in any way.
7. Participants must respect the possessions of others. Participants may not touch,
damage, or steal anything that does not belong to them. (Please note that the Valley
Worship Center and Brooktondale Nazarene Camp and Retreat Center are not
responsible for any missing or stolen objects.)
8. Participant must not participate in any aggressive verbal or physical behavior
(pushing, shoving, name-calling), fight or threaten to fight anyone. Participant must
not be involved in any organized fight.
9. Participant must not participate in ANY sexual comments, sexual actions, threats, or
activity. Participants may not posses any sexually explicit or suggestive music,
photographs, or media/materials of any kind.
10. Participants must not bring drugs, use drugs, or sell drugs at any time. (Including
banned substances and over-the-counter medications.)
11. Participant must not possess or carry any weapons at any time. (Including but not
limited to firearms, knives, explosives, or chemical substances.)
The police will be called at any sign of suspicious activity. Campers involved in the
above activities will be sent home.
I have read the above rules and agree to support the Valley Worship Center in them and
will abide by them.
Parent/Guardian Signature: _________________________________ Date: ___________

Child/Participant Signature: ________________________________ Date: ___________

Medical Form
Name: _________________________________________
Birth Date: _____/_____/______
Male or Female
Address: ________________________________
________________________________

City: _______________________________ State:______________ Zip:_____________

Home Phone: _______________ Work: ________________ Cell: __________________
Family Physician: ________________________________
Phone: _____________________
Address: ________________________________
________________________________

City: _______________________________ State:______________ Zip:_____________

Name of Health Ins. Co. or Medicaid ID#
________________________________________________________________
Applicants Under 18:
Documentation of immunization for the following diseases MUST be submitted with
this form. Acceptable documentation would be a copy of school, home or physicians
records. Mumps, Measles, Rubella (MMR), Diphtheria, Polio Tetanus (DPT)

Documentation Received ______

Has applicant had:
Y / N Appendix removed
Y / N Fainting Spells
Y / N Seizures/Convulsions
Y / N Chicken Pox

Y/N
Y/N
Y/N
Y/N

Asthma Diabetes
Hernia Measles
Heart Problems
Kidney Disease

Please List Allergies:

______________________________________________________________________
______________________________________________________________________
____

Please List Medications:

______________________________________________________________________________________
______________________________________________________________________________________

Medications for those under 18 must be pharmacy labeled, and upon registration,
presented to the nurse with a written prescription slip from their physician stating
dosage directions.
Medication ______ Slip ______
Other pertinent information:
______________________________________________________________________________________
______________________________________________________________________________________

*Minors will NOT receive over-the-counter medications at any time during camp.

Signatures required for applicants under 18 years of age.

I hereby give permission for ______________________________ to participate in all
camp activities except the following:
_____________________________________________________________________
(Or state none.)
I, the parent/guardian of _____________________ understand that in cases of medical
emergency, every effort will be made to contact me. In the event that I cannot be reached,
I hereby give permission to the camp nurse or physician(s) selected by authorized
personnel of the Upstate New York District Church of the Nazarene and The Valley
Worship Center Church of the Nazarene to hospitalize and to otherwise secure proper
emergency treatment including injection, anesthesia, or surgery for the above named
child. I, the undersigned, do, for myself, my heirs, personal representation and assignees
waive and release any and all rights and claims for damages against the Upstate New
York District Church of the Nazarene The Valley Worship Center Church of the
Nazarene, their agents or authorized persons, for any and all injuries which may be
suffered by me or my child, except that provided through insurance benefits.
___________________________________
(Parent/Guardian Signature)
__________________________________
(Please Print Name)
___________________
(Date)

EMERGENCY CONTACT:
Name: ________________________________________________________
Phone: _________________________
Name: ________________________________________________________
Phone: _________________________
No camper or volunteer minor should be in possession of any medications. We cannot
administer over-the-counter medications. Prescription medications are to be sent in the
original container with clear label, and be accompanied by note from physician. All
should be placed in a Ziplock bag and turned over to the nurse upon registration at camp
and picked up before you leave camp at the end of the week.

DISCLAIMER
INDEMNITY AND HOLD HARMLESS AGREEMENT
I/we hereby grant permission for my child to participate in Urban Camp for which I am
registering. I agree to indemnify and hold harmless Valley Worship Center, Safe Place,
and any other entity associated with the program, their officers, agents and employees
from any liability, claim or action arising out of such participation. I understand that this
program is not bound by the responsibilities and legalities that accompany a licensed
daycare program. I further certify that my child is in good health and has no physical or
other impediment, which would endanger him/her, or any other participant in taking part
in such an activity.
CONSENT TO TREAT A MINOR
I certify that I am the parent or legal guardian of the child being enrolled in this program.
I hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical
diagnosis rendered under the general or special supervision of any member of the medical
staff and emergency room staff licensed under the provisions of the Medicine Practice
Act or Dentist licensed under the provisions of the Dental Practice Act and on the staff of
any acute general hospital holding a current license to operate a hospital from the State of
New York Department of Public Health. It is understood that this authorization is given
in advance of any specific diagnosis, treatment or hospital care required but is given to
provide authority and power to tender care which the aforementioned physician in the
exercise of his/her best judgment many deem advisable. It is understood that effort will
be made to contact the undersigned prior to rendering treatment to the patient, but that
any of the above treatment will not be withheld if the undersigned cannot be reached.
This consent will remain in effect until rescinded in writing.
CONSENT FOR FIRST-AID TREATMENT
I hereby authorize the staff to provide immediate first aid to my child in the event of
illness or injury.
CONSENT FOR TRANSPORTATION
If this program provides for the transportation of my child, I hereby grant permission to
Valley Worship Center or Safe Place staff member to provide such transportation.
PHOTOGRAPHIC RELEASE
I hereby give Valley Worship Center, Safe Place, it's successors and assigns, the absolute
and irrevocable right and permission with respect to photographs, videos, motion
pictures, and/or sound recordings being taken of my child: (a) to use, reuse, publish and
republish in whole or in part and (b) to use my child's name. I further release Valley
Worship Center, Safe Place and any other entity from any claims and demands arising
out of the use of same.
Parent/Guardian of: ______________________(print camper name)
X_____________________________________(print parent/guardian name)
X_____________________________________(sign parent/guardian name)
Date: _____________________

Deposit/ Work Waiver Form

_____ I have enclosed $10 Registration Fee for Urban Camp.
_____ I have completed the below Work Waiver Option consisting of 3 days of work at
either the summer lunch program or the church nursery.

DAY 1:

Camp Director Signature: __________________________

Camper Applicant Signature: _______________________

Date: ___________
Circle one: Lunch Program or Church Nursery
DAY 2:

Camp Director Signature: __________________________

Camper Applicant Signature: _______________________

Date: ___________
Circle one: Lunch Program or Church Nursery
DAY 3:

Camp Director Signature: __________________________

Camper Applicant Signature: _______________________

Date: ___________
Circle one: Lunch Program or Church Nursery

$10 is due with the submission of registration packet. If you cannot pay this fee, you can
opt for work credits by working at the summer lunch program or in the church nursery for
three days. See Pastor Clare for work times and approval.