Arrival at Camp *

MM

DD

YYYY

Departing from Camp *

MM

DD

YYYY

Travel Mode *

Boat (via Tanana)

Aircraft (via Nenana)

Other

Skill Set (Check all that apply) *

Plumbing

Electrical

Carpentry

HVAC

Mechanic

Heavy Equipment Operator

General Maintenance (painting, cleaning, etc.)

Cook

Welding

Other

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Marital Status *

Single

Married

Divorced

Engaged

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 Number *

(###)

###

####

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 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 planes cannot carry passengers weighing 300 lbs or more

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