Counselor and Adult volunteer registration

1. 1
Join us for a second year at our Catholic Kids Camp!
2015 Counselors and Adult Volunteers
DATES: Monday June 22- Friday June 26, 2015
TIMES: 8:30AM – 12:15PM
LOCATION: St. Thomas the Apostle R.C. Church Corporation
Parish Center Building
208 East Avenue
Norwalk, CT 06855
Participant Name: ____________________________________________________________________
Age (if 12-17 years): __________ Shirt Size: ________
Parent Name (if 12-17): _______________________________________________________________
Address: ____________________________________________________________________________
City: _______________________________________ State: _____________ Zip: _________________
(circle one) (circle one)
Day Phone: __________________ Guardian/ Participant: ________________________ Home/ Cell
(circle one) (circle one)
Other Phone: __________________ Guardian/ Participant: ______________________ Home/ Cell
Do you or your child need special accommodations? If so, please explain:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

2. 2
Please check all that apply:
_____I am interested in being a Group Leader. (Lead Counselor in a group of campers)
_____I am interested in being a Station Leader. (i.e. crafts, bible stories, etc.)
_____I am interested in providing one-on-one help to a child with special needs.
_____I am interested in working with pre-schoolers.
_____I am interested in working with 1st
- 3rd
graders.
_____I am interested in working with 4th
– 5th
graders.
Note: Indicating interests does not guarantee placement in those areas.
ATTENTION
Mail all forms to: St. Thomas the Apostle R.C. Church
ATTN: VBS Registration
203 East Avenue
Norwalk, CT 06855
Food Allergy Alert!
I am allergic to _______________________________________________________________
_____________________________________________________________________________.
Do you use an epi-pen? _______________________________________________________
Are you able to self-administer? ________________________________________________

3. 3
St. Thomas the Apostle R.C. Church Corporation
2015 Catholic Kids Camp
Photo Permission and Release Form
I hereby give permission to St. Thomas the Apostle R.C. Church Corporation (referred to as
“St. Thomas”) and the Diocese of Bridgeport and its agents and representatives to take
photographs, make artistic renderings, and or make film, video or audio recordings of me or
my child (whose name is set forth below) while s/he is participating in camp-sponsored
activities for so long as s/he is at Camp.
In addition, I hereby give permission to St. Thomas to use such photographs, renderings,
film, video and audio recordings in perpetuity for any purpose and in any manner it deems
appropriate by the STA, in any media, including, without limitation, print, video and web-
based uses. I understand that such use may include, without limitation, use in connection with
school yearbooks, newsletters, brochures, websites and promotional materials. I understand
that St. Thomas and the Diocese of Bridgeport has complete editorial discretion with regard
to use of such photographs, renderings, film, video and audio recordings and that I will not
be compensated in any way for any such use.
I release and forever discharge St. Thomas and the Diocese of Bridgeport, its affiliates,
officers, agents, representatives and successors from any claims, costs, liabilities and or
expenses arising from any use of such photographs, renderings, film, video and audio
recordings, including, without limitation, any claims of invasion of privacy, defamation,
violation of publicity rights, and hereby hold St. Thomas the Apostle R.C. Church Corporation
and the Diocese of Bridgeport and its agents harmless from and against such claims.
Name of Counselor or Adult Volunteer: ________________________________________________
Signature of Participant (if 18+) or Parent/Legal Guardian: ________________________________
Printed name of Parent/Legal Guardian (if applicable): ___________________________________
Address of Participant (if 18+) or Parent/Legal Guardian: _________________________________
_____________________________________________________________________________________
Date: __________________________