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2013 Breakaway Volunteer Page

 
This year's Breakaway / Superhero Summer -- UCC's summer day camp will run from July 15th thru July 19th!

Please fill out the information below and hit the button at the bottom of the page, and you will be taken to the a confirmation page where you will submit this form.

(*Items with an asterisk are the areas that have the greatest need for volunteers.)

THANK YOU SO MUCH FOR VOLUNTEERING!
 

    • Volunteer Contact Information

    • Name *


    • Date of Birth *

    • Address *







    • Home Phone *



    • Cell Phone



    • Work Phone



    • Email (very important - this is how we will communicate) *

    • Your Home Church: *

    • If your child(ren) will be attending Breakaway - Names of Children:

    • Grade Child(ren) will be entering in Fall 2013

    • Positions You Would Like to Volunteer In

      Please select only one job during the week of Breakaway (you can also select Pre-Breakaway and/or After-Breakaway jobs as well).

      Volunteers entering 7th or 8th grade in the Fall 2013: You will be part of the Navy SEALs (Special Elite Assistant Leaders) Team. Please check your area of interest below.
    • Days Available During Breakaway (July 15 - 19)





    • Check here if you are going into the 7th or 8th grade in the Fall 2013


    • Jobs the Week of Breakaway

    • PreSchool & Kindergarten



    • Elementary (1st - 6th Grades)





    • Small Groups (1st - 6th Grades)


    • Other Positions During Breakaway










    • Jobs Before and After Breakaway Week

      These can be selected in addition to your service during the actual week of Breakaway
    • Pre-Breakaway Jobs








    • Post-Breakaway Jobs

    • Permission Statements - Volunteer


      MODEL RELEASE: For promotional purposes, videos and photographs are taken at Breakaway 2013. Your registration constitutes permission for University Covenant Church to use your picture in promotional materials.

    • LIABILITY RELEASE: I understand that Breakaway is conducted by University Covenant Church through its employees, volunteers, participants and others acting on University Covenant Church’s behalf, all of whom are referred to together as “UCC” in this liability release. In consideration for the services provided through Breakaway, I hereby agree to release and discharge all of the parties referred to as UCC above as follows:

    • I voluntarily choose to participate regardless of the risks in participating in Breakaway. These include, without limitation, risk of physical injury, men- tal injury, emotional distress, trauma, death, and the effects of weather, including extreme temperatures or conditions. I expressly agree to accept and assume all risks arising from, or relating to, my participation in Breakaway, including the risk of acts or omissions by UCC constituting ordinary or gross negligence. I assume these risks on my own behalf.

    • This release form is completed and signed of my own free will with the purpose of participating in Breakaway. I have had a sufficient opportunity to read this entire document. I have read and understood it, and I agree to be bound by its terms.
    • Volunteer Name *


    • I understand, acknowledge, and grant permission by initialing here: *

    • Date *

    • Volunteers Serving the Week of Breakaway, Please Also Fill Out Info Below ...

    • T-Shirt Info


      (only for volunteers serving during Breakaway week)

    • Emergency Medical Information


      (while you are at Breakaway)
    • Primary Contact Name


    • Primary Contact Home Phone



    • Primary Contact Cell Phone



    • Primary Contact Work Phone



    • Your Physician

    • Physician's Phone / Address

    • Medical Insurance Provider

    • Medical Insurance #

    • Special Circumstances / Physical Limitations (health, food, allergies, etc)

    • If yes to medication, please explain:

    • Spiritual and Ministry History

    • If yes to Jesus, please explain:

    • Briefly list any previous experience in Children's Ministry, Breakaway, or Vacation Bible School:

    • For Small Group Leaders and Assistants


      Please note that we cannot guarantee requests

      Please note: This does not register the child for Breakaway. A separate Child Registration Form must be filled out for kids 3 years and older who are potty trained (underwear only).
    • If you are a parent and would like your child in your group, please put down their name and grade in Fall 2013:

    • If there is another volunteer you are requesting to lead with, enter their name below:

    • If you want your child placed in childcare (for ages 0 to 3 yrs old), enter their name and date of birth below:

    • For children 0–3 years please indicate any allergies or special needs:


Authentication Text*
(Enter the text in the image above into this field.)

NOTE: Do Not Alter These Fields: