Adult/Sponsor Certification Form

Church Information

Church* (If you are attending camp with a different church, please provide the name of YOUR church)

Phone*

Address*

City* State* Zip*

Adult Volunteer Sponsors

Add as many adults/sponsors as needed. This section is unlimited.

Please check off if the following have been completed.

Note: At least one adult/sponsor is required.

Attestation by Pastor/Minister/Church Leader

The above named individuals are known to me/us, and I/we can attest to the character, integrity and ability of each to serve as a sponsor. I/we know of no reason why any should not serve as a sponsor for children and youth under the age of (18) eighteen. I/we also attest to the fact that each of these sponsors has undergone a background check as mandated by the State of Texas and meets the requirements set forth by The Texas Department of State Health Services Rule §265.12 and has successfully completed the required Child Protection Training.

Authorized Representative Signature (TYPE NAME)* Name Printed* Date*

OPTIONAL SECOND SIGNATURE LINE:

Authorized Representative Signature (TYPE NAME) Name Printed Date

After submitting, you’ll see a printable confirmation page.