Online Summer Camp Application Form

Thank you for your interest in the Highlands Camps in Belgium, Cambodia, and Mexico this coming summer!
Personal Information
Full Name (as appears on your passport)*
First NameMiddle NameLast Name
Preferred Name
Student ID*
Cell Number*
Area CodePhone Number
E-mail (@liberty.edu)*
Date of Birth*
MonthDayYear
Gender*
MaleFemale
Class*
Major*
Minor
Cumulative GPA*
Marital Status*
SingleMarried
If you don't mind, take a quick picture for us!
Travel Information
Have you talked with your parents about going to Belgium, Cambodia, or Mexico this summer?*
YesNo
Are your parents supportive of you participating in an overseas camp? Please explain.*
Do you have a passport?*
YesNo
From what country is your passport issued?*
When does your passport expire?
MonthDayYear
Please select the camp you'd like to participate in:*
Please select each of the travel blocks you would like to participate in the Belgium Highlands Camp.
June 19-23June 26- June 30July 3-7July 10-14July 17-23July 25-Aug 2Aug 3-10Aug 12-20
Please select the dates that you would like to serve at Highlands Camp Mexico
May 31-June 14June 14-28June 28-July 12July 12-26July 26-Aug 9
Please select the travel dates for Highlands Camp Cambodia
July 1-15July 15-29July 29-Aug 19
Please select as many blocks of dates you would like to serve at camp. You may go for only one block or as many as all all of them – the cost will be basically the same regardless of how long you serve at camp.
Please tell us what interests you about participating in the camp you selected.*
Camp & Travel Experience
Please describe any experience or gifts that you have that are relevant to camp ministry? (If you do not have any prior experience, that’s okay!)*
Please tell us about any prior experience you have in countries outside of the US.*
Please list any foreign languages you speak and your level of fluency.*
Please rate your swimming ability.*

1 2 3 4 5
1 is I can't swim, 5 is I'm an experienced swimmer
Are you a certified lifeguard?*
YesNo
Are you certified in CPR?*
YesNo
Emergency Contact Information
Please provide contact information for two emergency contacts.
Emergency Contact #1
Relationship*
Full Legal Name*
First NameLast Name
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Home Phone Number
Area CodePhone Number
Mobile Number*
Area CodePhone Number
Work Number
Area CodePhone Number
E-mail*
Emergency Contact #2
Relationship*
Full Legal Name*
First NameLast Name
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Home Phone Number
Area CodePhone Number
Mobile Number*
Area CodePhone Number
Work Number
Area CodePhone Number
E-mail*
Medical Information
** THE FOLLOWING INFORMATION WILL BE KEPT CONFIDENTIAL. IT IS GATHERED SO THAT LU SERVE INT'L AND IMPACT YOUTH WORLDWIDE MAY BE ABLE TO BETTER CARE FOR EACH INDIVIDUAL. PLEASE TAKE THE TIME TO ANSWER EACH QUESTION AND FILL OUT THE INFORMATION THOROUGHLY. **
Do you have medical insurance?*
YesNo
Insurance Provider*
Policy #
Please list any food or medication allergies you have.*
Do you have special dietary preferences?
Do you have any environmental or other allergies not listed above?
Please list all current medications you are taking, their dosage amounts, and the reason you're taking them (include over the counter, herbal products, birth control pills, etc.)*
** The student is responsible for all medications that must be taken during the trip. Take care to bring the necessary medications in their original containers. **
Medical History
** Please answer each question honestly by checking Yes or No. If you answer yes to any of the following please explain the space provided. This information will not necessarily disqualify you from going to serve at a Highlands Camp. **
Heart Disease/Problems?*
YesNo
Specify:*
Asthma*
YesNo
Last Attack*
Other respiratory problems?*
YesNo
Explain:*
Seizures?*
YesNo
Last Occurrence*
Eating Disorder?*
YesNo
Explain:*
Intentional bodily injury?*
YesNo
Explain:
Risk of immune deficiency?*
YesNo
Explain:*
Pregnancy?*
YesNo
Due Date:*
Intestinal or stomach problems?*
YesNo
Specify:*
Depression or other mental health/emotional issues?*
YesNo
Explain:*
Any other diseases or disability not listed? Please explain.
Is there anything that would prohibit you from fully performing what would be expected of your participation on this trip?*
YesNo
If yes, please explain:*
Relationship with Jesus
Please describe how you became a follower of Jesus.*
0/0
Please describe your current relationship with Jesus.*
0/0
Should be Empty:

Personal Information

Travel Information

Camp & Travel Experience

Emergency Contact Information

Medical Information

Medical History

Relationship with Jesus