SOUTH TEXAS YOUTH CAMP YOUTH LEADER CHECK LIST

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2 YOUTH LEADER CHECK LIST Pray and fast for our South Texas Youth Camp. Complete ONE ONLINE registration for your church youth group and workers at Print out the Camp Individual Registration and Health Forms. Have each camper fill out the health form and turn them into you. Bring them with you to camp. Print out the Youth Worker Forms. Have all youth workers fill out youth worker forms and turn them into you. Bring them with you to camp. Print out the Group Registration Form. Fill it out. Have your pastor sign it. Bring it with you to camp. Review guidelines with campers and workers. /Call Seth Simmons if you have questions. Contact info below. COMPLETE REGISTRATION BY MAY 21. HAVE FUN AT CAMP!

3 INFORMATION 1. What is youth camp? An incredible four-day camp just for the youth of the South Texas District UPCI. You will experience a powerful move of the Holy Spirit, Apostolic ministry and Biblical teaching, fellowship, food, sports, fun, and much more. We re anticipating over 700 youth to share this experience with us. 2. How much is youth camp? $150 per camper if registered by May 21. $175 after May 21 $100 for workers (must be 20 years or older to qualify for the worker rate) 3. What does this cost include? Includes all of your main meals, lodging, incredible amenities, and dynamic Apostolic preaching and worship for the entire week! 4. Who gets to come? The youth camp is available for all teenagers and young adults from the age of 12 to 21 years old. If an 11 year old child will turn 12 by the end of the year, then they may register. We encourage each group to have their own leaders who stay in the dorms with their group. The leader/camper ratio at youth camps is 1 leader per 10 youth. 5. How do I sign up? Fill out ONE ONLINE registration form for your church s youth group and all workers, including yourself, at Print out the Country Camp Health Forms, Youth Worker Forms, Group Registration Form, and all other info online. Have all youth and youth workers from your church turn in their forms to you and bring them with you to camp. You will turn these forms in on the first day of camp. 6. How do I pay? Payments are made online when you fill out the church registration online. 7. What happens if I cancel? Once the final number of attendees is submitted, groups are responsible to pay the complete balance for all of the total number of attendees submitted. 8. What facilities and activities are available? Our camp is at the beautiful Country Camp: 1423 County Rd.101 Columbus, TX 78934, a 1088-acre Christian camp facility with a 2,000 seat venue, full service cafeteria, A/C dorms, concessions, 440 ft waterslide, 52ft high double-waterslide, horseback rides, go-carts, swimming pool, sand volleyball courts, and basketball courts. 9. Will our group stay in the same dorm? The time at camp is a special time for youth group unity. Our goal is to keep each group together. If a group is divided, we will work with the leader of the group to get the best arrangements possible. Late registrants, however, can not be guaranteed being housed with their group. 10.When do I arrive and depart from the youth camp facility in Columbus, TX? Youth Camp check-in begins at 3:00pm on Monday, June 4. We are not allowed on the property before then. Check-in and registration will be from 3:00pm-5:00pm. Your registration time will depend on when you registered. The first to register get early check-in times. The departure time is 11:00am on Friday, June 8. Early release for groups will not be permitted barring extenuating circumstances.

4 REGISTRATION INSTRUCTIONS 1. Fill out ONE ONLINE registration form for your church s youth group and all youth workers, including yourself, at This will ensure that your group is housed together and make registration run more smoothly. a. Fill out ONE ONLINE REGISTRATION FORM for your church youth group and workers, including yourself, at b. Print the CAMP INDIVIDUAL REGISTRATION AND HEALTH FORMS have each camper fill out a form and turn it into to you. c. Print YOUTH WORKER FORMS have all youth worker s fill out the form and turn it into to you. d. BRING THE FOLLOWING FORMS WITH YOU TO YOUTH CAMP. i. One Group Registration Form Have your SENIOR PASTOR SIGN GROUP REGISTRATION FORM for your church in order to verify the information on the group application. It will not be accepted without a pastoral signature. ii. All of the Camp Individual Registration and Health Forms iii. Youth Worker Forms 2. LATE REGISTRATION FEE is $175 and will be charged to all campers who register after MAY 21. a. Late registrants register at the camp check-in on Monday, June 4. b. No late registrations will be guaranteed a place in the dorms with a pre-registered or other designated church group. c. No group can save beds for un-registered Campers. d. The availability of space can not be guaranteed. Late registration will end when the Country Camp s capacity is reached. 3. On-site REGISTRATION will be from 3:00pm-5:00pm on Monday, June 4. a. No groups will be allowed on the camp grounds before 3 p.m. b. When you arrive remain in vehicle and follow directions given by camp staff personnel. c. Send your whole group in to checkin, obtain armbands, pay for late registrants, and get dorm assignments. d. If you are pre-registered but are running late, please call ( ). 4. DORM ASSIGNMENTS It s important that campers go to their assigned dorm and room, so we do not displace larger groups that arrive later. We ask that our leaders help us ensure that every group is in its correct area. We will have additional leaders helping direct people. 5. ALL CAMPERS MUST DEPART FROM THE CAMPUS BY 11:00 AM FRIDAY MORNING.

5 GROUP REGISTRATION FORM Church Name Church Phone Senior Pastor s Name Phone Youth Leader/Contact Person s Name Home Phone Cell Phone Total Count of Attendees* = (Including Adult Chaperones) Total Male Count = Total Female Count = PLEASE ATTACH A LIST OF THE FIRST & LAST NAMES OF EVERYONE ATTENDING WITH THIS FORM *The number of campers you enter should match your ONLINE registration number. If not, extra campers will be considered late and you will be responsible to pay $175 for the additional campers. Estimated time of arrival: (Registration is from 3:00PM 5:00PM) PLEASE READ Consent and Certification I, the undersigned, with the consent of the parents or legal guardians of the minors in our group, do hereby consent to the participation of our group in all scheduled activities during the South Texas District Youth Camp, and any other activities customarily associated with this camp. Further, I certify that every attendee is physically fit and adequately prepared to participate in all sporting events. I am personally aware of the nature of the activities conducted at Country Camp in Columbus, Texas. I have advised the applicants of all camp rules and their obligation to abide by them, and I hereby pledge to uphold the camp in all the Youth Camp policies and recommend all attendees for admission into Youth Camp. Medical Treatment Authorization I understand that I will be notified in the case of a medical emergency along with the parents. However, in the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill. I authorize the camp staff to make emergency medical care decisions on behalf of my child. I understand that the South Texas District UPC will not be responsible for medical expenses incurred solely on the basis of this authorization. I agree to notify the Youth Camp in the event of any health issues which would restrict anyone in our group from participating in any normal youth camp activities. I also understand that the adult supervisors reserve the right to restrict my child from any activity that they do not feel is within the physical capabilities of my child. Senior Pastor Date Signed Youth Leader or Chaperone Date Signed

6 GUIDELINES FOR CAMPERS DON T FORGET TO: Fill out the Country Camp Individual Registration & Health Form with parental signature and turn it into your youth leader. Have the information from the Youth Camp Registration Packet explained to you. Check with your church leaders for all available information concerning the camp. Prepare your heart to receive all Jesus has for you at STX YOUTH CAMP! BRING Bible Linens/Sleeping Bag Pillow Towels Toiletries Flashlight Dress Clothes, Casual Clothes, Active Clothing Swim suit Spending Money DON T BRING Water Guns/Water Balloons Weapons Fireworks Skateboards/Roller Blades Valuables (Each camper is responsible for their own items.)

7 GUIDELINES FOR CAMPERS (Please review with youth group.) Dress Boys - The following items are prohibited: Girls - The following items are prohibited: Shorts, jams, or short pants Skirts and/or slits that come above the knee Extremely short-sleeved shirts or tank tops Shorts, pants, or clothing that appears to be All jewelry (rings, necklaces, etc.) shorts Mustaches, beards, or long sideburns Extremely short sleeves, capped sleeves or Any other immodest apparel tank tops While swimming dark-colored t-shirt All makeup (eyeliner, lipstick, etc.) must be worn. All jewelry (rings, necklaces, etc) Be fully covered to and from swimming area. Immodest apparel While swimming dark-colored t-shirt must be worn. Be fully clothed to and from swimming area. Conduct The following conduct and items are prohibited: Cursing Disobedience Disrespect to Camp and Country Camp Staff Public display of affection Skipping class or church Abusing Country Camp property Disobeying youth workers Throwing water balloons, cups, or buckets of water, or shooting water guns, etc. Shaving cream misuse and/or abuse Fighting Out of the dorm after curfew Media: ipods, radios, etc. Other conduct that is not conducive to the spiritual nature of this camp Grounds for Immediate Dismissal The following conduct is subject to immediate dismissal from camp: Any combination of three issues listed above Sexual promiscuity Possession or use of illegal drugs, alcohol or tobacco Fighting Possession of knives, firearms or any illegal weapon Vandalism of camp property Possession of pornography Destroying another camper s Leaving the grounds without authorization personal items from the Executive Committee Theft

8 COUNTRY CAMP INDIVIDUAL REGISTRATION AND HEALTH FORMS (Page 1 of 3) Camp dates attending: Arrive / / Depart: / / Have you ever attended Discovery Camp before? ٱٱ Yesٱٱ No (This side to be filled in by parents/guardian of minors or by adult campers/staff members themselves.) DO NOT FAX THIS IN Name: last first initial Birthdate / / Sex: ٱٱ M ٱٱ F Age: Camper Social Security # - - Church Name: (For ages 17 and under) Both Parents or Guardians (or Spouse): 1: last first Home Address: - - city state zip phone 2: last first Home Address: - - city state zip phone If not available in an emergency, notify: last first Home Address: - - city state zip phone

9 COUNTRY CAMP INDIVIDUAL REGISTRATION AND HEALTH FORMS (Page 2 of 3) Health History: Check & give approximate dates ٱٱ Frequent ear infections ٱٱ Heart defect/disease ٱٱ Convulsions ٱٱ Diabetes ٱٱ Bleeding/clotting disorders ٱٱ Hypertension ٱٱ Mononucleosis ٱٱ HIV-AIDS ٱٱ TB ٱٱ Cancer Allergies ٱٱfever Hay ٱٱ Other drugs ٱٱ Ivy poisoning, etc ٱٱ Asthma ٱٱ Insect stings ٱٱ )Other (specify ٱٱ Penicillin Has this camper ever required any psychiatric counseling or hospitalization? Yes No Explain: Operations or serious injuries (dates) Disability or chronic or reoccurring illness: Activities encouraged or limited by physician: Dietary Modifications: Current medications (send with instructions): Name of dentist/orthodontist: Phone: ( ) - Name of family physician: Phone: ( ) - Do you carry family medical/hospital insurance? ٱٱ Yes ٱٱ No If so, indicate: Carrier Policy or group # Phone ( ) - Suggestions on health related information for camp personnel For Female Only Has this person menstruated? ٱٱ Yes ٱٱ No If not, has she been told about it? ٱٱ Yes ٱٱ No If so, is her menstrual cycle normal? ٱٱ Yes ٱٱ No Special Consideration: Immunization History This page must be filled in. Required immunizations must be determined locally. Please record the data (month and year) of basic immunizations and most recent booster doses. Vaccines Year of basic immunization Year of last booster Diphtheria Pertussis (Whooping Cough) Tetanus or Tetanus Diphtheria or Tetanus Oral polio (Sabin) TOPV Injectable Polio (Salk) DPT TD Measles(hard measles,red measles, Rubeola) Mumps Rubella (German measles, 3-day measles) Other Tuberculin test given (most recent) Haemophilus influenza b (HIB)

10 COUNTRY CAMP INDIVIDUAL REGISTRATION AND HEALTH FORMS (Page 3 of 3) REGISTER BY MAY 31 Important This Box Must Be Completed For Attendance This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed camp activities except as noted. Authorization for treatment: I hereby give permission to the medical personnel selected by the camp director to order X-rays, routine tests, treatment, and necessary transportation for me/or my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization, for my child as named above. The completed forms may be photocopied for trips out of camp. I hereby release Discovery Camp, Burchfield Ministries, all camp workers, and Tommy and Rachel Burchfield, and the South Texas District from all liability, personal and/or property, and grant permission to Discovery Camp nurse, Columbus Community Hospital or another medical facility to administer any necessary first aid and/or any medical treatment needed in case of an emergency. Parent/Guardian Signature Date / / Health Care Recommendations by Licensed Physician Only if under physician s care I have examined the above camp applicant within the past two years. Date examined / / In my opinion, the above s condition ٱٱ does ٱٱ does not preclude his/her participation in an active camp program. Height Weight Blood Pressure The applicant is under the care of a physician for the following condition(s): Current treatment (include current medications) Explanation of any reported loss of consciousness, convulsions, or concussions: Does applicant have epilepsy? Yes No Does applicant have diabetes? Yes No Recommendations and Restrictions While at Camp Any treatment to be continued at camp: Any medication to be administered at camp (specific dosages): Any medically prescribed meal plan or dietary restrictions: Any allergies (food, drug, plants, insects, etc): Additional health information: Licensed Physician s Signature Address: City: St: Zip: Phone: ( ) - Date of Form Completion / / By: If completed by nurse or physician s assistant

11 GUIDELINES FOR YOUTH WORKERS (Please review with all adult chaperones.) Successful Discipline Discipline with a Smile 1. Follow the three warning rule: a. First give warning for inappropriate or disrupting behavior. b. Second, if the problem continues, have the youth stay with you and lose privileges for as long as your determine. c. Third, if previous two solutions do not help, bring the youth to your church leader or a member of the South Texas Youth team for further discipline. 2. Discipline in Love 3. Don t blow up. 4. Don t destroy their dignity, using ridicule, shame, or sarcasm. 5. Allow kids to be kids. (It s alright for kids to act crazy sometimes, as long as they don t enter into an area of comprise, such as dangerous behavior or rebellion to authority.) 6. Let them know what you expect out of them. 7. Don t be afraid to confront inappropriate behavior. 8. Discipline is for the benefit of others. One person should not ruin the experience for others. 9. Give the benefit of the doubt. Ask yourself, was the conduct willful or just careless. Careless behavior may just warrant words of caution, not actual punishment or deprived privileges. 10. Don t be afraid to ask for help. 11. Get the story straight. Hear both sides before administering disciplinary actions. 12. Pray after discipline. This will let the camper know that you care about them. Dorm Supervision 1. Curfew: each leader is responsible to see that all campers in his group are accounted for and in their dorm by curfew. 2. Lights out: once a time is determined for lights out by the dorm leaders, youth should respect this time and not be disruptive. 3. Leader Presence: there should always be adult leadership in the dorms if youth are present. 4. Special Medical Cases: be aware and make nurse aware of any pre-existing physical conditions of campers in your group 5. Be Sensitive to Others 6. Personal Items: consistently remind those in your group and dorm not to leave personal items or valuable unattended 7. Cleanliness: all leaders monitor dorm cleanliness and see that areas are kept neat and presentable 8. Keep your eyes open: some youth may make plans for a late-night rendezvous after curfew. Leaders should strategically position themselves by the doors of the dorm to prevent such attempts. 9. Stop things when they first start: All leaders should be sensitive and quick to put a stop to any friction or inappropriateness 10. Don t Overlook Anyone: Make sure that everyone feels a part of the group. Don t let anyone be an outsider.

12 YOUTH WORKER FORM (Page 1 of 2) All attending adults must complete and turn in this youth worker form. This application must be completed in full by all applicants seeking any position involving interaction with, or the supervision of young people. It will be used to help the South Texas District provide a safe and secure environment for youth who participate in our camps. Church Name First Name Middle Name Last Name Age Address City, State Zip Driver s License Issue State Date of Birth Sex Home Phone Cell Phone List any other churches you have attended regularly during the past five years: Name of Church Pastor s name Name of Church Pastor s name Are You Baptized in Jesus name? Yes No Yes No Have You Received Holy Ghost? Position applying for (must choose one): Monitor Dean / Matron Other Have you ever worked at a South Texas District YOUTH CAMP? No Yes When? / / Have you ever been convicted of or pleaded guilty to a crime? No Yes If yes, explain:

13 YOUTH WORKER FORM (Page 2 of 2) References Name Phone Address City/State/Zip Name Phone Address City/State/Zip Name Phone Address City/State/Zip TO BE COMPLETED BY SENIOR PASTOR AS THE SENIOR PASTOR, I AM NOT AWARE OF ANY REASON WHY THIS WORKER SHOULD NOT BE ALLOWED TO WORK WITH YOUTH CAMPERS. TO MY KNOWLEDGE THERE HAS BEEN NO RECORD OF PHYSICAL OR SEXUAL CHILD ABUSE IN THE APPLICANT S HISTORY. I RECOMMEND THE APPLICANT TO BE ACCEPTED AS A YOUTH CAMP WORKER. I have have not conducted a background check on the applicant. (No application will be accepted without Pastor s signature.) Senior Pastor s Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Senior Pastor Date Signed Youth Worker Consent and Certification The information contained in this application is correct to the best of my knowledge. I authorize any references or churches listed in this application to give you any information (including opinions) that they may have regarding my character and fitness for YOUTH ministry. I understand a criminal record and background check will be conducted as a result of this application. In consideration of the receipt and evaluation of this application by the South Texas District YOUTH DEPARTMENT, I hereby release any individual, church, youth organization, charity, employer, reference, or any other entity, including record custodians, both collectively or individually, from any and all liability for damages of whatever kind or nature which may arise to me, my heirs, my family, on account of compliance or any attempts to comply, with this authorization. I waive any right that I may have to inspect any information provided about me by any person or organization identified by me in this application. Should my application be accepted, I agree to abide by and be bound by the Bylaws of the South Texas District United Pentecostal Church, and the YOUTH CAMP policies, and will fulfill the job description given to me by the Executive YOUTH CAMP Committee, and refrain from unscriptural conduct in the performance of my services on behalf of the district. I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement which I have read and understand. I HAVE HAVE NOT COMPLETED THE STAFF TRAINING SESSION PROVIDED BY THE SOUTH TEXAS DISTRICT UNITED PENTECOSTAL CHURCH. Youth Worker s Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Youth Worker Date Signed