Peacemakers' Day Camp

Teen's Name:

Date of Birth:

Sex:
Male Female
Email:

Lives With:
Both Parents Mother Father Joint Custody Other
Father's Name:

Father's Phone Number(s):

Guardian's Name:

Emergency Contact's Name:

Emergency Contact's Phone Number(s):

Ethnic Background (optional):
Asian Black/African-American Hispanic/Latino(a) Native American (American Indian) White (Caucasion) Mixed Race Other I prefer not to answer
Religious Background:

Have you been a teen helper at Peacemakers' Day Camp before?:
yes no
Have you been a camper at Peacemakers' Day Camp?:
yes no
Please explain why you would like to be a teen counselor, and what skills you can contribute:

I will come to the teen orientation and to the camp set-up Sunday evening. I agree to arrive on time for Peacemakers' Day Camp, to keep my attention on my teen helper job, to stay for after-camp clean-up and meetings, and to act as a peacemaker with other people, including children, other staff, and parents. It I have a conflict, I will work it out nonviolently or will ask the help of the camp director or one of the teachers. As much as possible, I will try to be at camp full time. Teen's Electronic Signature (Initials):

I will allow any pictures or videos taken of my teen at camp to be used in Peacemakers' Day Camp publications:
yes no
Parent/Guardian's electronic signature (initials):