2025 Counselor in Training for Peace Camp

Counselors in Training will have a MANDATORY training on Sunday, May 18th at UUCCI/ Interfaith Campus 7850 W. Goeller Rd Columbus, IN from 1-3pm with light lunch provided.

I understand and have marked my calendar to plan on attending the Training

Yes! I have an unavoidable conflict and need find another time to meet with directors

Counselor in Training Name

How would you prefer your name on your nametag?

Pronouns (she/they), (ze/zir), etc

T-Shirt Size

adult-small adult-medium adult-large adult-X Large adult-XX Large

Volunteer (Age at Time of Camp)

Counselor in Training Contact & Communication Information

This address will receive a confirmation email

Best Phone # to reach you at

Can we contact you via Text Messaging?

Yes No

Primary Mailing Address

Volunteer Commitment and Interest

Have you volunteered with Peace Camp at UUCCI in the past?

Yes No

Are you affiliated with Columbus Interfaith? If so, please indicate your organization or community at large

First Presbyterian First United Methodist Islamic Society Sha'arei Shalom Sri Ganesh Mandir Tree of Knowledge Coven UUCCI Community at Large

Please share your experience working with children or what skills/ passions you are excited to share at Peace Camp.

References

We would like the name and phone number of two adults who can provide references for you, your ability to help with younger children, and your dependability as a volunteer. References should not be related to the applicant.

Reference Name and Phone Number

Parent and Guardian Information

Parent/Guardian Name

Parent/Guardian Email

Parent/Guardian Phone

Can we contact you via Text Messaging? Yes No Option

Medical Information (ALL VOLUNTEERS)

Who is the best person to contact in the event of a medical emergency?

Alternative medical emergency contact if person above cannot be reached

Please share any relevant medical or special instructions we may need to know about you while you are in our care at Peace Camp. This could be allergies, fears, concerns to help keep them safe, etc.

Do you have any Food Allergies?

YES. Life Threatening- will provide more information and epi-pen will be sent with child to camp. Yes, not life threatening None known at this time

If you answered YES above, please list any known Food Allergies

Do you have any Skin Allergies?

Yes None known at this time

If you answered YES above, please list any known Skin Allergies (ie: if they come into contact with something in nature or play)

Are you allergic to bees or stinging insects?

YES- Life Threatening. We have an epi pen we will make sure comes with them Yes, not life threatening Not known to us at this time

Any other medical concerns (emergent or non-emergent) we need to know to keep you safe, ie: asthma, epilepsy, diabetic, etc.

Medical Authorization for Peace Camp

I hereby authorize the Peace Camp staff of UUCCI (paid or volunteer) to take any reasonable action to obtain emergency medical care for me or my youth and absolve them of any liability for such action. I hereby authorize any emergency medical, surgical, diagnostic, and hospital care, treatment of procedures deemed immediately necessary or advisable by emergency medical technicians, a physician, or a hospital to safeguard me or my youth's health in the event I cannot be easily contacted. I also agree to be responsible for any medical expenses not covered by my insurance.

Adult Name and relationship to youth

Photo Permission

If you give permission to photograph or videotape your children while participating in UUCCI Programming, please sign this standard Media Release Form. These photos may be posted within the church and/or published on the church website or Facebook page. Names of children in the photos will not be published.

Media Release Form

Unitarian Universalist Congregation of Columbus Indiana (UUCCI)

On occasion, UUCCI takes photographs and/or videos of adults and children in action as they participate in the congregational events such as worship, RE Classes, Peace Camp, and social justice action. UUCCI would like to be able to use these images to promote UU activities and our congregation to the broader community. We commit to do so with respect and consideration, and only for the purpose of promoting the mission and principles of UUCCI. Photos and videos shall not reveal personal information, never identifying youth or children by names or addresses.

Photo Permission

Yes (see below) No- Please DO NOT photograph my child

I hereby authorize UUCCI, as an adult for myself OR as the parent and/or legal guardian of the child/children listed below, to photograph and/or videotape these children while they are participating in UUCCI activities, RE Programming (such as Peace Camp, Youth Group, UU services, UU social action, etc.) and any other time they are on UUCCI property. These photos and recordings may be displayed or shared by UUCCI within the church and/or published to the broader community, whether on the UUCCI social media accounts such as its website or Facebook page or other channels, to further UUCCI's mission and principles. No minor will be identified by name, and no private information about the minor will be published.

Parent/Guardian Legal Name

Today's Date

2025 Counselor in Training for Peace Camp

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