Team Leader Application Form

MAKE SURE YOU COMPLETE ALL SECTIONS BEFORE YOU CLICK SEND:

Personal information, Medical / Insurance information, Staff Medical Release

You must be 21 or older to be a team leader

* required fields

First Name*
Last Name*
Address 1*
City*
State*
Zip Code*
List other names that you are known by*
Email*
Phone*
Gender*	Male Female
Date of Birth
T-Shirt Size*	S M L XL XXL
Masjid Name
Masjid Phone
How do you intend to use your skills to make Kamp Khalil a success?
Essay*
Do you have any previous experience working with youth?	Yes No
If yes, please detail your experiences below
Please enter 3 reference names and numbers below
Reference 1*
Reference Phone1*
Reference 2*
Reference phone 2*
Reference 3*
Reference phone 3*
STAFF MEDICAL RELEASE FORM
Full name*
Primary Physician info
Phsician Name
Physician Phone
Health Insurance info
Insurance Carrier*
Policy Number*
Carrier Phone*
Liability Release*	I hereby release the Kamp Khalil, their agents, employees, and volunteers from any and all liability for all personal injuries known or unknown that I may incur due to reasons unrelated but not limited to negligence by participating in activities conducted, sponsored, or associated with the event stated above.
Allergies and pre-existing conditions
In case of emergency, please contact the persons listed below
Emergency 1*
relationship*
Emergency 1 Phone*
Emergency 2*
relationship*
Emergency 2 Phone*
Physician Release*	I do hereby authorize a physician selected by the coordinator of this event to administer emergency treatment including medications, diagnostic tests, surgery, or other medical intervention deemed necessary by the physician.
Todays Date*
Signature*	By checking this box, I disclose that I have read this release and understand all its terms. I execute it voluntarily on behalf of myself with full knowledge of the significance to bind. In witness whereof, I have signed this release on the date indicated above.