Online Staff Registration Staff Registration Staff Personal InformationParent / Legal Guardian InformationIndividual Health Record Staff Personal InformationFirst NameLast NameGender- Select -MaleFemaleAddressAddress Line 1Address Line 2CityStateZip CodeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwePhone NumberDate of Birth (Click on year and type in birth year)T-Shirt Size (Sizes are adult)- Select -SmallMediumLargeX-LargeXX-LargeXXX-LargeEmailCamper's WELS/ELS Home CongregationChurch CityChurch State- Select -CANVAZWITXAge I am 18 years or olderPreviousNextStaff Volunteer InfoI am interested in the following staff position(s): Activities Leader Bible Study Leader Cabin Shepherd Hike Leader Kitchen Staff Crafts Leader/Assistant Campfire Music Leader Office Driver Photographer Canoe Supervision Guitar / Musician Devotion Presenter Life Guard (with Red Cross Cert Card) Infirmary (EMT or above) Archery Supervision(Please keep in mind that we may not be able to honor all requests)Notes:Emergency Contact InfoFirst NameLast NameRelationshipPrimary PhoneSecondary Phone I Agree In checking this box, I, , do hereby authorize GSBC to use any pictures that may be taken of me during the week to be used in future GSBC marketing materials and websites. I Agree In checking this box, I, , do hereby authorize the above named camper to attend Good Shepherd Bible Camp (GSBC) during the dates listed above. In addition I authorize GSBC to use any pictures that may be taken of my child during the week to be used in future GSBC marketing materials and websites.Method of Payment ($60) PayPal Venmo Check CashPreviousNextIndividual Health RecordQuestionnairePlease review the following questions In the last 3 months:Any injuries? (head, knee, etc.) Yes NoHospitalized? Yes NoSurgery? Yes NoPassed out / experienced dizziness? Yes NoJoint problems? Yes NoUnexplained fever? Yes NoHigh blood pressure? Yes NoEating disorders? Yes NoChest pain? Yes NoDiabetes? Yes NoInsulin Dependent? Yes NoDiarrhea? Yes NoConstipation? Yes NoMigraines / headaches? Yes NoAsthma? Yes NoPLEASE BRING INHALERSeizures? Yes NoHeart murmur? Yes NoHistory of bed wetting? Yes NoPsychological disorders? Yes NoDiagnosisLast Menstrual Cycle (Month/Day)Last Tetanus (Month/Year)ClarificationAllergiesPlease note if you have a history of severe allergic reactions. If so, please ask your doctor to prescribe an epinephrine auto injector (EPI-PEN or AUVI-Q) to bring to camp.Medications (Check any medications you DO NOT want used on yourself) Acetaminophen Swimmers Ear Drops Benadryl Tums Gentamicin Ointment A&D Ointment Bethamethasone Cream Saline (to cleanse wounds) Alcohol Sudafed Ibuprofen Cough Drops Glucose Tabs Hydrocortisone Cream Burn Gel Nasal Saline Spray Wound Spray Aloe Gel (for burns) Miralax Naproxen Imodium Triple Antibiotic Ointment Zinc Oxide Cream Benadryl Gel Eyewash Peroxide Tea Tree Oil OTC or Allergy Medication*We do keep pepto-bismol for our adult staff only I Agree In checking this box, I, , do hereby authorize that I have read the list above and give permission to Good Shepherd Bible Camp staff to dispense items not checked as needed. I Agree In checking this box, I, , do hereby authorize that I have read the list above and give permission to Good Shepherd Bible Camp staff to dispense items not checked to my child as needed. I Agree In checking this box, I, , authorize Good Shepherd Bible Camp to arrange for necessary transportation to the nearest medical facility, specifically an ambulance, appropriate to the condition for urgent or emergency medical treatment, and I do assume all responsibility for payment for such treatment. I hereby give permission to the physician at the receiving facility to secure and administer any medical treatment deemed necessary for my child, including hospitalization. I Agree In checking this box, I, , authorize Good Shepherd Bible Camp to arrange for necessary transportation to the nearest medical facility, specifically an ambulance, appropriate to the condition for urgent or emergency medical treatment, and I do assume all responsibility for payment for such treatment. I hereby give permission to the physician at the receiving facility to secure and administer any medical treatment deemed necessary for my child, including hospitalization. ALL MEDS MUST BE TURNED IN TO NURSING STAFFIf taking prescription medications, bring in the original prescription bottles. These identify how medications must be taken. If there are any changes to the order, please notify the nursing staff immediately.Number of Prescribed MedicationsMedicationDoseTimes TakenReason I will bring the original prescription bottles Previous Submit Form
