Street Address

City, State, Zip

Phone Number

Your Custom Text Here

Counselors

Suryoyo Summer Camp Counselor Form '23

Counselor Full Name

First Name

Last Name

Parent/Guardian Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Date of Birth

YYYY

Age at the start of camp

T-shirt size

Hobbies and abilities

Teach Syriac, Soccer referee, etc.

What would you like to get out of your involvement with Suryoyo Summer Camp?

Availability

Emergency Contact Name

First Name

Last Name

Emergency Contact Number

(###)

###

####

Are you a returning counselor?

Yes

If so, what position?

INJURY WAIVER

Full name of counselor

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent(s) or Guardian(s)

First Name

Last Name

Release of Liability

By signing this Release Form, I expressly warrant that the Youth named above is capable of withstanding both the physical and mental demands of the planned activities. I also expressly assume all risks of the Youth whether such risks are known or unknown to me at this time. I further release Archdiocese of the Syriac Orthodox Church for the Eastern US and its Archbishop, Priest, leaders, employees, volunteers, and agents from any claim that my Youth may have against them as a result of an injury or illness incurred during the course of participation in the activities. This release of liability shall include (without limitation) any claims of negligence or breach of warranty. This release of liability is also intended to cover all claims that members of the Youth’s or my family or estate, heirs, representatives, or assigns may have against the Archdiocese of the Syriac Orthodox Church for the Eastern US or its Archbishop, Priest, leaders, employees, volunteers, or agents.

Transportation during Church Functions

By signing this form, I give permission that the Youth named can be transported, as the activities require, by the approved staff or volunteers of the Archdiocese of the Syriac Orthodox Church for the Eastern US.

First Aid & Emergency Medical Treatment

I do hereby give permission for agents of Archdiocese of the Syriac Orthodox Church for the Eastern US to seek and secure any needed medical attention or treatment for my Youth including hospitalization. I give permission for attending physician(s) and other medical personnel to administer any needed medical treatment, including surgery. In so doing, I agree to pay all fees and costs arising from this action to obtain medical treatment.

I have read the above statement regarding Release of Liability, Transportation and First Aid & Emergency Medical Treatment.

I have read and agree with the above statements

Parent’s Digital Signature

First Name

Last Name

Cell Phone Number

(###)

###

####

Have you ever been convicted of a crime?

Yes

If you are 18 years old or older, do you consent to a background check?

Yes