Yellowstone Conference - Volunteer Application Form

Position ______Camp ______Dean/Manager ______

Name ______

(Last) (First) (Middle)

Resident Address ______

City, State, Zip ______, _____ , ______

Home Phone (_____)______-______Work Phone (_____)______-______

E-mail address ______

Birth date ____ / ____ / _____ Soc. Sec. # ______U.S. Citizen __yes __no

Previous staff experience with Yellowstone Conference camps ______

Other experience working with children or youth ______

Please help the camping committee plan future training by evaluating your skills and needs (Check all that apply)

Competency / I have received formal training in this area (X) / List who provided training and date completed / I would like training in this area
Faith sharing, Bible Study
Discipline; special needs
Music & Worship
Games; initiatives
Camper health & safety
Outdoor living skills
First Aid & CPR
Site Orientation
Other
And for Deans
Program administration
Program design
Staff recruitment, training
Other

Please complete Disclosure form on reverse side of this form

As an expression of the mission of the church which desires to ensure the safety and well-being of participants, guests and staff -- particularly children, youth, vulnerable adults and developmentally challenged persons -- Joining with many parents, legislative bodies and children/youth organizations, and other Annual Conferences, we require annual disclosures by all persons who will be working in our camp and retreat settings. ALL volunteers or hired persons who desire to work as staff persons must fill out this form completely and return it to the Dean prior to service each year.

If you have not been a camp volunteer for the Yellowstone Conference within the last two years, please list three persons who could serve as references. Preferably who have observed your work with children/youth (include address, phone, relationship and how long you’ve know them These persons will be contacted.):

1. ______

2. ______

3. ______

Disclosure - explain any “yes” answers below.

A. Have you used any illegal drugs in the past six months? Yes No

B. Have you ever been charged/convicted for any offense other than a traffic violation? Yes No

C. Have you ever been charged/convicted with child abuse or neglect? Yes No

D. Are there any other facts or circumstances that could call in to question your

being entrusted with the supervision, guidance and care of young people? Yes No

Explanation of any yes answers above:

______

I understand that:

A. The information I have provided may be verified, by contacting persons or organizations named in this application, or by contacting any person or organization that may have information about me. I hereby release and agree to hold harmless from liability any person or organization that provides information. I also agree to hold harmless the Yellowstone Conference Camping committee, The United Methodist Church, and the officers, employees and volunteers thereof and agree to abide by all decision of the Camp Dean, Camping Committee Chair or Conference Camping Coordinator.

B. In signing this application, I affirm that the information I have given is true, complete and correct and understand that I may be immediately terminated for any misrepresentations.

Applicant’s Signature ______Date ______

Pastoral recommendation (optional but suggested)

I have know the applicant for ____ years and can attest to his/her suitability as a staff member at a Yellowstone Conference camping event.

Pastor’s Name (print) ______

Signature: ______

Yellowstone Applicant Background Check Disclosure Affidavit

(Revised May 18, 2011)

The Yellowstone Conference screens prospective employees and volunteers to ensure the safety and well-being of participants, guests and staff—particularly children, youth, vulnerable adults and developmentally challenged persons. Joining with many parents, legislative bodies and children/youth organizations, we require disclosures by all persons who will be working in conference ministry settings including but not limited to: local churches, camping, UMVIM, youth events, and retreats.

All volunteers or hired persons who will participate in overnight or multi-day settings must fill out this form completely and return it at least two weeks prior to you beginning service. Information obtained does not automatically disqualify an applicant, but is considered on a case-by-case basis in view of all relevant circumstances. Completion of this affidavit and a background check is required by applicants in order to participate in Yellowstone Conference ministry areas. Please read and complete the requested information carefully, as any falsification, misrepresentation, or incompleteness in this disclosure is grounds for disqualification.

Name (Last, First, Middle)

Any Former Names (Last, First, Middle) & Date Used (e.g. Smith, Junior, B. 1987-2001)

Current Address Since_____ (street, city, state, zip code)

Date of birth (Month/Day/Year) Social Security Number

Phone number(s) Drivers License Number/State

List any City & State or City & Country or Territory where you have lived for the past 10 years, along with the year(s) you lived there (for example: 2005-present Helena, MT).

Have you ever been convicted of; pleaded guilty to (whether or not resulting in a conviction); pleaded nolo contendere or no contest to; admitted; had any judgment or order rendered against me (whether by default or otherwise); entered into any settlement of an action or claim of; had any license, certificate or employment suspended, revoked, terminated, or adversely affected because of; been diagnosed as having or been treated for any mental or emotional condition arising from; or resigned under threat of termination of employment or volunteer work for; any allegation, any conduct matter, or thing (irrespective of the formal name thereof) constitution or involving (whether under criminal or civil law of any jurisdiction)**:

Yes No (Initial under “Yes” or “No” for each item.)

______Any felony.

______Rape or other sexual assault.

______Drug or alcohol related offenses.

______Abuse of a minor or child, whether physical or sexual.

______Incest.

______Kidnapping, false imprisonment, or abduction.

______Partner/Family Member Assault.

______Sexual harassment.

______Sexual exploitation of a minor.

______Sexual conduct with a minor.

______Criminally annoying/molesting a child.

______Lewdness and/or indecent exposure.

______Lewd and lascivious behavior.

______Obscene literature.

______Assault, battery or other offense involving a minor.

______Endangerment of a child.

______Violation of a protection, restraining, or no-contact order.

______Any misdemeanor or other offense classification involving a minor or to

which a minor was a witness.

______Unfitness as a parent or custodian.

______Removing children from a State or concealing children in violation of a law

or court order.

______Restrictions or limitations on contact or visitation with children or minors.

______Similar or related conduct, matters, or things.

______Accusation of any of the above.

If you answered “Yes” to any of the above, please describe the circumstances including the dates. If none, write “None”.

The above statements are true and complete to the best of my knowledge.

______

Date Applicant’s signature

______

Date Witness to signature

**The source for this form is “Guidelines for the Screening of Persons Working with Children, the Elderly, and Individuals With Disabilities in Need of Support” (U.S. Department of Justice, Office of Juvenile Justice and Delinquency Prevention).