2018 New Life Summer Camp Staff Application

First Name ______Last Name ______

Age ______Birth Date ___/___/____Place of birth______Gender ______(M/ F)

Social Security # ______Driver’s license #______State Issued______

Address: City ______ST__ Zip _____ Phone ______

Cell Phone ______Email Address ______

Church Name ______

Church Address ______City ______State ______Zip ______

Church email address: ______

Pastor Name ______Pastor Phone______

Pastor Email ______

Marital Status: ______Married ______Single ______Divorce

Emergency Contact Name ______Phone # ______

Height ______Weight ______Eye Color ____ Hair Color ______

Personal Insurance Company ______Policy # ______

I understand that the Local Church Insurance policy will provide secondary Medical coverage. My insurance company is primary. I accept any and all medical costs in case of an accident or serious illness, you have my permission to secure the proper medical treatment. I understand that I will not hold Camp Elkanah, New Life Summer Camp, or the Church of God liable while involved in the camp.

Local Church Ins.Co ______Insurance Policy # ______

General Medical Information:______

Do you have any Health problems or physical limitations? ______

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List any Physical Handicaps you may have:______

______

On medications and purpose for them? ______

Gluten Free Diet: yes / no (please circle one)

Allergy Information: ______

Have you ever been convicted of or pled guilty to a felony? ______

Have you ever been charged with or pled guilty to an assault, sexual abuse or child abuse? _____ If you

Yes, please explain. ______.

Spiritual Status: Saved ___ Sanctified _____Holy Ghost Baptized____ Baptism in water ______

Member of your church ______.

Your Hobbies: ______

Church Activities ______

______

Occupation ______

Previous Camp Experience. ______

All staff will receive a free T-Shirt if registered and accepted by June 1st(Circle your size) Adult S Adult M

Adult L Adult |XL Adult 2X Adult 3X

Position Desired: Counselor ___ Canteen ___Teaching ___ Recreation ___ Food Service ___ Nurse ____ Maintenance ___ Media ___ Security ___ Other ___

If you have been notified that you have been accepted as staff, it is mandatory that you attend the Pre-Camp training 07/31/2017! Campers are not allowed on the camp grounds until after 1 pm on Monday!!!

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I certify that all of the above information is true. I agree to comply with and abide by any and all rules and regulations of the New Life Summer Camp as set forth by the New Life Summer Camp Director and staff. I further agree to any and all background checks which shall be deemed necessary by the New Life Summer Camp. I will attend the mandatory Pre- Camp Training Session on Monday (07/31/17 at 3:30 Pm)

Your Local Church’s Lead Pastor Recommendation is Required.

I certify that I know the above applicant and he/she is a capable and qualified person to work in the New Life Summer Camp. I give them my highest recommendation to serve with youth/children in any capacity deemed necessary by the Camp Director.

Lead Pastor Signature ______

Statement of Reservation

While no one is rejected to work or attend New Life Summer Camp on the basis of gender or race, the New Life Summer Camp does reserve the right to accept or reject any application for volunteer work at New Life Summer Camp after review of said application reveals that the services of the applicant would not be needed or are not in the best interest and success of the camp. Please initial your agreement here. ______

All staff are asked to pay $12.00 per night. for the camp rental. (This helps to keep the camp cost down for the campers.)

Church Ck ______Personal Ck ______Total______Please check one.

Only confirmed staff should arrive for Orientation/ Camp. Bring Confirmation letter with you.

Please return your app as soon as possible.

Applicant signature: ______

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