Personal Information
Participant First Name
Participant Last Name
Participant Preferred Name
Gender
Male
Female
Date of BirthFormat: mm/dd/yyyy
Grade Completed at End of Current School YearIf applicable
6th 7th 8th 9th 10th 11th 12th College
Shirt SizeAdult Sizes
S
M
L
XL
XXL
XXXL
XXXXL
XXXXXL
Street Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Home Phone
Cell Phone
Email Address
Please List Other Family Members Attending Camp
Parent Information
If registration is for youth
Parent First Name
Parent Last Name
Parent Cell Phone
Parent Email Address
Emergency Contact Information
Please list two contacts, other than a Parent/Guardian, who would be allowed to pick up the participant.
1. Emergency Contact
1. Emergency Contact Phone
1. Emergency Contact Relationship
2. Emergency Contact
2. Emergency Contact Phone
2. Emergency Contact Relationship
Vehicle Information Required if bringing vehicle to be used at camp
Vehicle Type
Number of Seatbelts
Medical Information
Are there any Medical Conditions or Accommodation the Safety Team needs to be aware of?
No
Yes
If yes, please explain:
Will there be any Medications taken at camp?
No
Yes
If yes, please explain:
We want to help your student have a successful camp experience. Are there any Special, Mental, or Behavioral health needs the camp staff needs to be aware of beforehand?
No
Yes
Please check all that apply:
Depression/Suicidal Concerns
ADD/ADHD
Autism
Behavioral/Oppositional Difficulties
Special Accommodations Needed
Communication Difficulties
Other
Please explain:
Are there any Food Allergies or Special Dietary Needs the Kitchen Staff and Safety Team need to be aware of?
No
Yes
If yes, please explain:
Name of Medical Insurance Company
Name of Medical Insurance Policy Holder
Medical Insurance Policy Holder DOB
Medical Insurance Group Number
Medical Insurance Phone Number
Skills And Experience
Have You Attended U.M. ARMY Before?
Yes
No
If Yes, How Many Times Have You Attended?
What Was The Last Year You Attended U.M. ARMY?
Adults, Check The Leadership Roles In Which You Are Willing To Serve
Camp Director
Program Coordinator
Administrative Coordinator
Kitchen Coordinator
Safety Coordinator
Site Coordinator
Tool Coordinator
Color Group Leader
Work Team Adult
Please Rate Yor Skills On A Scale Of 1 - 3
First Aid
1 - Novice
2 - Intermediate
3 - Expert
Music
1 - Novice
2 - Intermediate
3 - Expert
Roofing
1 - Novice
2 - Intermediate
3 - Expert
Carpentry
1 - Novice
2 - Intermediate
3 - Expert
Administrative Skills
1 - Novice
2 - Intermediate
3 - Expert
Food Service
1 - Novice
2 - Intermediate
3 - Expert
Rules And Agreements
The below Covenant Agreement and Press and Medical Release information is new. This replaces the previous paper forms that were turned in. Please read each section carefully.
Covenant Agreement
I will treat both the client and their property with dignity and respect.
I will treat all participants respectfully in accordance with the teachings of Christ. As a Christian Role Model, I will encourage all volunteers to assume leadership roles and to conduct themselves with a Christ-like attitude. I will seek to build them up and not tear them down.
I will show proper respect for the host church, vehicles and tools. I will conduct myself in a thoughtful, safe manner at work and at play.
I will participate fully in all camp activities and with a positive attitude will focus my energies to promote unity within the camp.
I will abide by the following vehicle regulations:
Seatbelts to be worn at all times
No youth may ride in a vehicle driven by anyone under 21 years of age
No riding in pickup truck beds or trailers
I recognize I will be relied upon to provide leadership especially at times when safety and issues of discipline are being compromised.
I will adhere to the following rules and regulations established by U.M. ARMY:
Radios, tape/disc/mp3 players, cell phones for youth are not permitted
Alcohol, illegal drugs and tobacco products are not permitted
No one may enter the dorm of the opposite sex
Everyone must dress appropriately
I will read the U.M. ARMY Travel Guide and will abide by and adhere to all that is printed within.
By checking here I acknowledge that I have read, understand and agree to the U.M. ARMY Covenant Agreement.
Press and Medical Release Terms
I wish to volunteer my services with U.M. Army Youth Mission Program. I acknowledge and agree that the nature of the services to be performed include but are not limited to physical labor, building repairs, yard work, construction, and the use of power tools, other construction tools, ladders, scaffolding, lawn mowers, gardening equipment and tools. I further acknowledge and agree that the services to be performed during the Program are inherently dangerous and pose a substantial risk of injury or death and of damage to or loss of personal property;
I acknowledge that the risks of participation also include, but are not limited to, the risks of travel; the risks of negligence, gross negligence, willful and wanton misconduct and/or bad judgment by me or other participants, including the clients, coordinators, volunteers, and site inspectors; contact with unidentified and unfamiliar persons; and the risks of failure, misuse and malfunctioning of equipment;
I hereby represent that I am in good physical condition and health, am capable of safely performing the activities for which I have volunteered and do not pose a risk of harm to myself or other participants;
I assume, to the greatest extent permitted by law, all of the risks to me, whether or not specifically identified herein, of all the activities in which I participate and the services I use and/or provide;
I release U.M. ARMY, its directors, officers, employees, trustees, agents, volunteers, coordinators, participants, equipment providers, and Program clients, and covenant not to sue such persons for, any and all liabilities, actions, causes of action, demands, damages (including but not limited to any illness, death, bodily injury, personal injury or property damage) and claims of every kind or nature, either in law or equity, which arise or may hereafter arise out of any activity associated with or my participation in the Program;
I authorize publication, broadcast or other use of my name, photograph, likeness, image, voice and biography in any and all media, publications, advertising, and publicity arising out of any activity associated with the Program without further compensation and agree that all such materials are the sole property of U.M. ARMY.
On behalf of myself and my heirs, I indemnify and hold harmless U.M. ARMY, its employees, trustees, volunteers, coordinators, participants, equipment providers, and Program clients from any and all costs, liabilities and claims, of every kind and nature whatsoever, arising directly or indirectly, from my participation in activities or use of services, including any legal costs and expenses and the costs of medical or other expenses incurred for my benefit.
I authorize any of the leaders of U.M. ARMY to obtain any and all necessary medical and/or dental attention and/or treatment for me, including surgical procedure if advised by the attending physician. I have listed on the registration form (front side), any and all special medical problems concerning myself, and I confirm that I have advised the leaders of U.M. ARMY of any special medical problems.
By checking here I acknowledge that I have read and agree to the Press and Medical Release terms.
Signature
By my signature below I acknowledge that I have read, understand and agree to the U.M. ARMY liability, press and medical release above. I have also read the Covenant of Conduct above and agree to abide by it. I affirm that all the information on the U.M. ARMY Individual Registration form is correct.
A value is required.