Check which Camp you plan to attend *

High School

Discipleship

Jr. High

Elementary

Area of Service *

Check all that apply

Bible Teaching

Worship Team

Kitchen Staff

Counselor

Maintenance Crew

Medical

Activity Leader

Photography

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Marital Status *

Single

Engaged

Married

Divorced

Home Church Phone *

(###)

###

####

Name of Pastor who recommended you *

First Name

Last Name

Home Address *

Address, City, State, Zip

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact *

(###)

###

####

Parent/Guardian Name *

If under 18 years old

First Name

Last Name

Emergency Contact *

First Name

Last Name

Primary Phone of Emergency Contact

(###)

###

####

Secondary Phone for Emergency Contact

(###)

###

####

Emergency Contact Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Insurance Phone

(###)

###

####

Primary Doctors Name *

First Name

Last Name

Doctors Office # *

(###)

###

####

Do you habitually use tobacco/marijuana in any form?

Yes

No

Do you habitually drink alcohol? *

Yes

No

Have you used illegal drugs in the last year? *

Yes

No

Do you have any allergies *

Yes

No

Do you have dietary restrictions? *

Yes

No

Have you been convicted of child abuse or felony? *

Yes

No

Is there anything else we should know about you or your past which may bring us concern in your service as a team member with KHBC? *

Yes

No

I have fully and truthfully answered the above questions *

First Name

Last Name

I understand that because of the camp's remote location, medical treatment, including emergency life saving treatment, could be delayed or unavailable. I accept this liability risk and agree to hold Kokrine Hills Bible Camp, its board, leaders and staff faultless in the event professional medical care is delayed or unavailable. *

First Name

Last Name

I hereby give permission for emergency medical treatment to be administered to me and I agree to be financially responsible for such treatment.

First Name

Last Name

I have never been convicted of a felony, or any sex-related or violent offense.

First Name

Last Name

I understand that Kokrine Hills Bible Camp will be taking video and still photos throughout the camp season and give permission for them to use video/photos of me in various camp promotions and/or on the camp website, social media, and other video content related websites. *

First Name

Last Name

I understand and acknowledge that I must bring a soft duffle bag for travel weighing no more than 30 lbs

First Name

Last Name

I understand and acknowledge that the KHBC plans cannot carry passengers weighing 300 lbs or more

First Name

Last Name

My pastor has recommended me and spoken with the director of KHBC in approval of serving as staff at KHBC this summer

First Name

Last Name

Applicant Signature

First Name

Last Name

Date *

MM

DD

YYYY

Signature of Parent/Guardian (if applicant is under 18)

First Name

Last Name