2023 Counselor Registration Form For Counselors that will be 17 or younger as of July 24, 2023. Step 1 of 3 33% Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Gender*MaleFemaleBirthdate* MM slash DD slash YYYY Grade as of May 1, 2023*9101112T-Shirt Size*Youth LargeAdult SmallAdult MeduimAdult LargeAdult XLAdult XXLCertifications* I am certified in CPR. I am certified in First Aid. I am a certified lifeguard. I do not hold any applicable certifications. Check all that applyParent Name* First Last Parent Email* Enter Email Confirm Email [email protected]Home Church Pastor's Name Tent InformationPlease only enter tent information if this same tent is not being entered on someone else's registration form.Bringing a Tent* Yes No Number of people tent sleeps as printed on tent package Tent Condition New Excellent Good Usable Poor Medical InformationEmergency Contact* First Last Relationship to Participant* Enter Emergency Contact Relationship - i.e. aunt, uncle, friend, neighbor, grandparent, etc.Emergency Contact Phone Number*Parent Primary Phone*Parent Home PhoneParent Work PhoneParent Mobile PhoneFamily Physician First Last Physician Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Physician PhoneInsurance Carrier* Insurance Plan # Insurance Policy # Last Tetanus Booster MM slash DD slash YYYY Blood TypeA+A-B+B-AB+AB-O+O-Allergies?* Food, insects, drugs, etc. - OR - NonePrescription Drugs* List all current prescriptions -OR- None (All medications will be held and administered by the camp medic.)Any Other Medical Concerns or Notes? Signature & PaymentBy applying to come to Camp Chi Rho, I agree to abide by all camp rules and requirements. I understand that failure to abide by the camp rules and requirements may result in being dismissed from the camp. All electronic devices are prohibited at Camp Chi Rho. This includes iPods, cell phones, Blackberries, Kindles, etc. Camp Chi Rho does not permit these items for reasons of safety, security, accountability, and the temptation to steal. If these items are found, the camp staff will confiscate them. I further agree to show proper respect to all camp counselors and fellow campers. I also promise to not damage or destroy any property of fellow campers, other individuals, Camp Chi Rho, or the Maryland State Government.I also certify that I meet the following requirements: I demonstrate maturity in Christian faith. My pastor knows my intent to be a Junior Counselor. I am committed to serving the campers and peers at camp. I am able to model positive characteristics for middle school students. I will attend and participate in 1 of 2 scheduled virtual training sessions to be scheduled in late June / early July. Please check all boxes that apply:Counselor Signature*Parent Signature*PARENT/LEGAL GUARDIAN: I certify that this counselor is in good health and has permission to engage in all camp activities. In case of accident or serious illness, I hereby authorize Camp Chi Rho to make whatever arrangements seem necessary. If Camp Chi Rho decides to obtain medical attention, I hereby authorize the medical experts to take whatever steps seem necessary for the health of the counselor. My insurance will serve as the primary coverage for all necessary medical treatment. I hereby release, discharge and/or otherwise indemnify Camp Chi Rho and its affiliated organizations, their employees and associated personnel including the owners of facilities utilized for Camp Chi Rho, against any claim by or on behalf of the junior counselor as a result of the counselor’s participation in Camp Chi Rho. I have noted any health factors or other stipulations for this participant in the medical section of this registration.Parent Signature*PARENT/LEGAL GUARDIAN: I hereby give this junior counselor permission to take part in activities in the water (swimming skills not required).How well does the camper swim? Swims Well Swims Fine Swims Poorly Cannot Swim Parent Signature*PARENT/LEGAL GUARDIAN: I hereby give this counselor permission to take part in any off-site activities. I also hereby authorize my child to be transported in a vehicle operated by a responsible adult driver associated with Camp Chi Rho. I also release, discharge and/or otherwise indemnify Camp Chi Rho and its affiliated organizations, their employees and associated personnel, against any claim by or on behalf of the camper as a result of the camper’s participation in any of these Camp Chi Rho activities. Parent Signature*CAPTCHA Δ