X/TwitterThis field is for validation purposes and should be left unchanged.Please fill out this form if you've received confirmation that you've been accepted as a CCA this year. We need this information to 1, confirm your place in the program and 2, pair you with your family evening childcare! Please contact us at CCA@npines.org if you have any questions.Please note, if you leave or refresh this page before successfully submitting the form, your progress will not be saved. To avoid losing your work, you can write the longer answers in a notes or document application and then copy and paste into the form fields.Section One: Your InformationName(Required) First Last Nickname or Preferred NameFor initial communication, our system will use your first name, but it is helpful to know if you go by a nickname.Gender Male Female Please confirm which weeks you will serve:(Required) Week 1 Week 2 Both Weeks Your Email Parent or Guardian's Email(Required) Enter Email Confirm Email Mailing Address(Required) My address has not changed since I applied My address has changed since I applied I don't remember which address I use for my application Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Age while at campT-Shirt SizeCCAs will receive a Northern Pines logo shirt which they will all wear on the first day. Small Medium Large Extra Large Other Health Release FormParents or guardians for all CCAs and Youth Campers need to fill out a health release form. Only one form is needed per student, even if they are staying both weeks. This form is available on the parent portal at npines.org/parent-portal My parent or guardian has submitted my health release form My parent or guardian will submit my health release form soon Section 2: ScreeningDo you use tobacco, alcohol or drugs?(Required) Yes No If yes to tobacco, alcohol or drus use, please explain(Required)Have you ever been convicted or pleaded guilty to a crime?(Required) Yes No If yes to convicted or plead guilty to a crime, please explain(Required)Section Three: Evening Childcare AssignmentThis portion helps us pair you with your children for the evening.Number of years of previous CCA experience?(Required)Please enter a number from 0 to 10.Would you like to watch the same children as last year?Not a guarantee, however, if they request you and you'd prefer not to be assigned to the same family, that is helpful for us to know! Yes No Indifferent Childcare Experience & Preferences(Required)Your evening childcare assignment will be done ahead of camp. (Check all that apply) I don't have a lot of babysitting experience I am comfortable with changing diapers (both babies and toddlers) I have experience with babies & would love to CCA for one I'd prefer an older child I am up for a challenge/Give me a family with many kids or 2 families I am not picky/I am willing to accept anything Sleep Needs(Required) I struggle with late nights I'm ok with a few later evenings (parents staying out past 11 pm) Other comments that may help us assign you to a family:Please let us know any limitations or preferences that will help us find the perfect assignment for you! Don't hesitate to share, any information is helpful. However, we prioritize pairing CCAs with families based on needs and qualifications, and will not be able to assign you near another specific CCA.ConsentI have been accepted to be a Child Care Assistant (CCA). I will arrive at the Northern Pines Conference in Green Lake, WI on Sunday of the week(s) that I will serve, by 2:00 p.m. (Transportation as necessary is additional and NO TRANSPORTATION IS PROVIDED IN BETWEEN WEEKS) I have read and understand the information given in the enclosed letter and realize both the privilege and responsibility for the task that will be assigned to me by the CCA Director, and the necessity for my personal commitment to the Lord, the children, and the program. I agreeCCA's SignatureParent or Guardian's SignatureToday's Date MM slash DD slash YYYY Section Four: Meals, Transportation, & Weekend LogisticsFor more information on the special meal requests, transportation, and transition weekend, please visit the parent portal at npines.org/parent-portalDietary Needs(Required)Special dietary meals are available for an additional $50 per person, per week. If you need a special meal (Gluten-free, dairy-free, etc.), please submit the special dietary request form I will not need special dietary meals I will need special dietary meals and already submitted that form I will need special dietary meals but have not submitted that form yet Transportation to GLCC(Required)There is a $25 fee for the bus each way. There is NO BUS TRIP in between weeks I am riding with my family I am riding with someone else I am taking the bus I don't know yet Contact Information — to GLCC(Required)Please provide the name and phone number of the person driving you to GLCC.Transportation from GLCC(Required)There is a $25 fee for the bus each way. There is NO BUS TRIP in between weeks I am riding with my family I am riding with someone else I am taking the bus to MN I don't know yet Contact Information — from GLCC(Required)Please provide the name and phone number of the person driving you to GLCC.Transition Weekend(Required)There is a $50 fee to stay at GLCC for the Transition Weekend (Saturday and Sunday between Week 1 and Week 2). Food, lodging, and optional activities are provided. I will stay on campus for the transition weekend I will not be on campus for the transition weekend and will not need lodging or meals for Saturday (lunch & dinner) or Sunday (breakfast & lunch) Summary of Fees & PaymentBus to Northern PinesBus from Richfield, MN to Green Lake, WI before Week 1 Price: Bus from Northern PinesBus from Green Lake, WI to Richfield, MN after Week 2 Price: Transition WeekendFood and lodging for Saturday and Sunday between Week 1 and Week 2 Price: How would you like to pay?(Required) Pay now online Will mail a check to PO Box 750 Lakeville MN 55044 Will pay via Zelle at npzelle@npines.org Transaction FeesFor online payments. This covers our fees so that 100% of your payment goes to Northern Pines. Thank you! Price: $50.00 Total due for transportation and weekend Credit Card(Required) CAPTCHA
