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ADULT FACULTY REGISTRATION
To be completed in full and mailed to: Camp Como, P.O. Box 36, Como, CO 80432
Event registering for: ________________________________
Date of Event: ______________________________________
List food or medication allergies/special dietary needs:
Faculty/sponsor name: _______________________________
List communicable diseases, serious illnesses or surgeries with
D.O.B. _____/_____/_____ □ Male □ Female
List any prescriptive or non-prescriptive medication which camper
City: ______________________ State:_____ Zip: ________
MUST TAKE REGULARLY
: (list additional med’s on back)
Medication (Dosage, Frequency, Reason Taking, Physician)
Church you attend: __________________________________
Church you are registering with: ________________________
Describe any special physical or emotional needs:
Emergency Contact Name: ____________________________
Emergency Contact Phone: ____________________________
WAIVER AND RELEASE
All information provided on this form is correct to the best of my knowledge. In case of emergency, I understand that every effort will be made to contact my
Emergency Contact. I give Camp Como permission to seek medical treatment for myself in case of emergency. I give Camp Como medical staff permission to
provide me with medical treatment which may include, but is not limited to: the use of Tylenol, Ibuprofen, Benadryl, Rolaids, Cough Medicine, Chlorpheniramine (allergy med), Benadryl Cream, Caladryl, Triple Antibiotic Ointment, Pseudofed, Claritin, or generic equivalents to these medications, physician consultation, urgent, emergent, and non-emergent medical treatment. I understand that the private health information on this form will only be used and shared for the purposes of medical treatment. I agree to indemnify and hold harmless Camp Como and their employees from any and all claims, damages, losses, injuries and expenses arising
out of or resulting from my participation in Camp Como activities.
Please Note any exceptions to treatment: _____________________________________________________________________________________
FACULTY JOB DESCRIPTION
As a volunteer junior faculty member, I am aware that my duties are t
o be done in compliance with the acting Program Director and the policies of Camp
Como during my stay. All of my responsibilities will come directly from them.
I also am aware that my personal conduct is to be Christ-like and appropriate for the
program that is in progress. I have not been convicted or accused of child abuse or misconduct.
I have read and agree to the “Faculty Job Description”.
Describe your duties for this week of camp:
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