Western Plains District

Applicant Information

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Birthdate *

Gender *

Email *

Email

Confirm Email

Cell Phone *

Home Phone *

Home Congregation *

Dietary Restrictions

Position Choices

Choice of Camp *

Camp Colorado
Camp Mt. Hermon

Choice of Camp Session (Camp Colorado) *

Pre-Junior (completed grade 3-4)
Junior (completed grades 5-6)
Junior High (completed grades 7-8)
Senior High (completed grades 9-12)

Choice of Camp Session (Camp Mt. Hermon) *

Come Along with Me (completed grades K-2)
Multi-age (completed grades 3-12)
Sr. High Weekend (completed grades 9-12))
Family Camp (all ages)

Choice of Position(s) *

If Counselor in Training, please fill out CIT application.

If Other position, list here *

Emergency Contact Information

Name *

First

Last

Relationship to you *

Home Phone *

Cell Phone *

Work Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Employment

If employed

Current Employer

Your Position

Employer's Address

Address Line 1

Address Line 2

City

State

Zip Code

Employer's Phone

School

For students

Name of School

Anticipated Date of Graduation

Degree Pursued

Experience

Experiences with Youth Work or Childcare *

Experiences with Camping/Outdoor Ministries *

Religious Background *

Reference Forms

Camps are required to keep reference forms from three (3) references on file for you. Reference forms are good for 10 years. Forms should come from persons who know you well and are not members of your family. Your application will not be complete until these forms have been received. The online reference form can be found here.

By typing my initials below, I am affirming that I have confirmed with the Western Plains District office (620-241-4240; office@wpcob.org) that I have 3 reference forms on file, and I understand that my application is not complete without the reference forms on file.

Initials *

Background Check

All staff are required to have a current background check on file with the district. For the current camping season, only those background checks done after July 1 five years previous are considered current (ex: for 2023 camping season, checks done after July 1, 2018 are current). Background check release forms can be found on the camps’ websites: www.campcolorado.org and www.campmounthermon.org. The form must be mailed to the district office: Western Plains District, PO Box 394, McPherson, KS 67460.

By typing my initials below, I am affirming that I have confirmed with the district office (620-241-4240; office@wpcob.org) that I have a current background check on file and that my application is not complete without a current background check.

Initials *

Health Form

All staff are required to have a completed health form on file at least two weeks prior to camp. Health forms are good for 1 year and can be found on the camps’ websites: www.campcolorado.org and www.campmounthermon.org. You can upload the Health Form below or mail it to your director.

Please also upload a copy (front & back) of your health insurance card below (unless you do not have health insurance).

Health Form Upload

Click or drag files to this area to upload. You can upload up to 4 files.

A picture of your completed Health Form is an acceptable format.

Health Insurance Card Upload

Click or drag files to this area to upload. You can upload up to 2 files.

Front & Back – A picture is an acceptable format.

Transportation

Driver's License *

Click or drag files to this area to upload. You can upload up to 2 files.

Please upload a copy of your driver’s license (front & back) – pictures are an acceptable format.

CPR/First Aid Training

CPR/First Aid training is preferred, but not required. If you do have this training, please upload your current certificate here.

CPR/First Aid Training Certificate

Click or drag a file to this area to upload.

Statement of Understanding Regarding Camper Transportation

Western Plains District camps often rely on staff to transport campers in their personal vehicles to offsite activities or to evacuate in case of fire or other emergencies. By typing your initials below, you acknowledge the following:

It is my responsibility to contact my auto insurance company to see whether my auto insurance will cover any incident that might occur while transporting campers during camps. I also acknowledge that the camp does not provide any auto insurance coverage and I affirm that my vehicle is in good working order and is in appropriate condition to safely transport campers and/or staff.

Initials *

COVID 19

By typing my initials below, I understand that campers and staff are expected to follow COVID 19 health guidelines. Guidelines for the 2023 camping season will be posted on the camp websites by 5/15/2023.

Initials *

Standard Precautions Training

Please upload a copy of your Procedural Safeguards Training completion certificate below.

Standard Precautions Training Certificate *

Click or drag a file to this area to upload.

Applicant's Statement

By typing my full name below, I agree to the Applicant’s Statement that follows:

I certify that the information contained on this application is correct to the best of my knowledge and understand that any omission or erroneous information is grounds for dismissal.
I agree to support and uphold the mission of the Western Plains District Camping Program.
I agree to operate under the policies and procedures of the camp(s) where I will be on staff.
I authorize Camp Colorado and/or Camp Mt. Hermon and the Western Plains District to photograph me and to use such photographs for the purpose of camp promotion, publicity or historical record.

Signature *

First

Last

Additionally for Camp Colorado staff only:

You will be contacted by a Camp Colorado staff person to be given instructions as to how to complete the state of Colorado background check process (in addition to the district release you should submit to the district office). Those forms must be completed by April 15.