Nurse Application

Personal Information
Name: *

First Name Last Name
Birth Date: *

Month Day Year
Phone Number:

Area Code Phone Number
E-mail Address: *
Address: *

Street Address

Street Address (Line 2)

City State / Province

Postal / Zip Code
Hometown (include city and state):
Name of Parish (include city and state: St. Patrick, Columbus, OH): *
Shirt Size: *

Educational History
Medical Training
Current/Most Recent Employment

Camp Experience & Qualifications
Name of Camp
Dates Served
Position/Role Description
Which of these certifications do you hold, or will you hold, by June 2020?

First Aid Certification Lifeguard Certification CPR/Emergency First Response None

Employment History
Previous Employer
Position/Role Description
Reason for Leaving
Previous Employer
Position/Role Description
Reason for Leaving
Previous Employer
Position/Role Description
Reason for Leaving

Safe Environment and Pastoral Care
At Damascus, we are committed to ensuring an environment of safety for our campers and to implementing person-focused pastoral care for all prospective missionaries. With this in mind, we want to be sure to walk with each individual person in their unique life experiences. In order to best do so, we ask the questions found on the next couple of pages.
Do you have a personal history of alcohol abuse? *

Yes No Request a Follow-Up Meeting Prior to Responding
Do you have a personal history of mental illness? *

Yes No Request a Follow-up Meeting Prior to Responding
Do you have any physical, mental, or emotional difficulties that might interfere with your ability to perform effectively as a missionary at Damascus? *

Yes No Request a Follow-Up Meeting Prior to Responding

Short Answer Questions

Part #1
How did you learn about Damascus? *
Why do you want to serve as nurse at Damascus? *
What talents, gifts, or abilities do you possess that would aid you in being a nurse at Damascus? *
In what ways do you want to grow during your prospective time with Damascus? *
In 4-6 sentences, describe your personal faith journey. *
How would you describe your relationship with the Lord? *
What is your dream for the Church in America? *

Short Answer Questions

Part #2
The following questions are based on our Missionary Mindsets. These are the five mindsets that guide the entirety of what we do at Damascus. We are Jesus-Centered, Mission-Focused, Joy-Filled, Obedient Toilet Plungers.
Jesus-Centered. What would a Jesus-Centered life look like? *
Mission-Focused. How would you define being on mission? *
Joy-Filled. What would you consider to be the characteristics of a joyful Christian? *
Obedient. Why is obedience important in our lives? *
Toilet Plungers. If a toilet plunger "takes care of messes," how, as Christians, can we positively embody a toilet plunger in the world today? *

References
References

Please list three (3) references that are familiar with you. Must be 21 years or older and not an immediate family member.
Reference 1
Name: *

First Name Last Name
Phone Number: *

Area Code Phone Number
Years Known: *
Relationship to You: *
E-mail: *
example@example.com
Reference 2
Name: *

First Name Last Name
Phone Number: *

Area Code Phone Number
Years Known: *
Relationship to You: *
E-mail: *
example@example.com
Reference 3
Name: *

First Name Last Name
Phone Number: *

Area Code Phone Number
Years Known: *
Relationship to You: *
E-mail: *
example@example.com

BCI/FBI Background Check
All persons age 18 or older (as of the first day of summer camp) and/or those who have not been residents of the state of Ohio for the last 5 years (consecutively) are required to provide a set of fingerprint impressions and proof of an Ohio Bureau of Criminal Investigation and Identification records check. (ORC §109.575 and Damascus Policies and Guidelines)

To complete this requirement, you may visit www.fastfingerprints.com to find a location near you, or you can find another fingerprinting company in your area. Please have them send the results to the Diocese of Columbus, with attention to Regina Quinn.
Which Criminal Background Check will you provide? *

I will be 18 or older at the start of summer camp, and I will complete and/or provide a copy of a BCI report as required, prior the start of summer camp. I have not lived in the state of Ohio consecutively for the last 5 years, and I will complete and/or provide a copy of an FBI report as required, prior to the start of summer camp.

Protecting God's Children
All persons age 18 or older (as of the first day of summer camp) will be required to verify participation in the Protecting God's Children (also known as "Virtus") safe environment training program, offered by the Diocese of Columbus and many diocese around the country, or an accepted equivalent training program from another diocese. To complete this requirement, you can find available sessions by visiting www.virtus.org.
With the above-listed information in mind, will you be 18 or older by the time camp starts? *

I will be 18 or older at the start of summer camp, and I will complete and provide record of my participation in the Protecting God's Children/Virtus safe environment training program, or its equivalent. I will not be 18 or older at the start of summer camp.

Legal Agreements
Release of Personally Identifiable Information:

1. I consent to the release of personally identifiable information.

2. Specific information to be released may include, but not be limited to: Photos, Name, Parish, School, Grade, City, State, Age, Personal Quotes (i.e. testimonials, etc.), and Parent(s)/Legal Guardian(s) Name(s).

3. Example reasons for release: Promotions, Fundraising, and Programming (to be potentially released via: Printed materials, brochures, flyers, videos, letters, web site, newspapers, radio, television, bulletins/newsletters, or transfer to a third party).

4. Additionally, the undersigned consent to the release of the information listed above by staff, volunteers, and other parties affiliated with Damascus.
Permission, Indemnification and Release, and Medical Power of Attorney:

1. I agree to participate in this program and hereby personally assume all risks in connection with my participation.

2. I am cognizant of the inherent dangers associated with participation in activities, which may include, but are not limited to: swimming, archery tag, rock wall climbing, mountain biking, hiking, canoeing, ropes courses, ground initiatives, paintball, field games, zip lines, campfires, tool use, etc.

3. I release from all liability and indemnify Damascus Catholic Mission Campus, as well as the Bishop/Diocese of Columbus and my local Parish/Bishop/Diocese and their officers, agents, representatives, volunteers, and employees from any and all liability, claims, judgments, costs and expenses, including attorneys' fees, arising out of any injury or illness incurred while participating in, or traveling to or from, these activities and further agree not to bring or prosecute or allow to be brought or prosecuted (including, but not limited to, prosecution through subrogation) in my name, or on my behalf, any claims, lawsuits or actions against them.

4. I understand that my participation is voluntary, and is a privilege and not a right, and that I elect to participate in spite of the risks.

5. I agree to cooperate with the event leadership.

6. I appoint the leadership of this event, as my attorney, in fact, to act for me in my name and my behalf, in any way that I would act if I were personally present, with respect to the following matters if any injury, illness or medical emergency occurs during the event or related travel: (i) To administer medications indicated. (ii) To give any and all consents and authorizations to any physicians, dentist, hospital or other persons or institutions pertaining to any emergency medications, treatments, diagnostic or surgical procedures or any other emergency actions as our attorney shall deem necessary or appropriate for my best interest. (iii) I understand that the leadership of this event will make a reasonable attempt to contact my family as soon as possible in the event of a medical emergency.

7. This power of attorney shall lapse automatically upon completion of the event and related travel.

8. This acknowledgement and release is intended to be as broad and inclusive as permitted by the law of the State of Ohio, and if any portion hereof is declared invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This acknowledgement and release shall be construed in accordance with the laws of the State of Ohio, except for the choice of law provisions thereof.

9. I am of lawful age and legally competent to sign this Permission, Indemnification and Release, and Medical Power of Attorney that shall be effective and binding upon me, and my personal representative or estate, assigns, heirs, and next of kin; that I understand the terms herein are contractual and not a mere recital; and that I have signed this document of my own free act and coalition. I have fully informed myself of the contents of this document by reading it, before having signed it.
Policy Agreement:

I agree that, in order to serve as a missionary at Damascus Catholic Mission Campus, I will be expected to act in accordance with all written policies and procedures as well as the training I receive. I agree that, prior to my work with Damascus, I will have attentively attuned to and agreed with the Policies and Guidelines, as described at the Equip Conference. This includes, but is not limited to, the Code of Conduct outlined in Policy 200.40 and the Harassment Policy outlined in 300.30. (Please ask for clarity at Equip Conference, if you have any questions, comments or concerns.
Signature *

Clear
Name *

First Name Last Name
Date *

Month Day Year
Date Hour Minutes AM/PM Option

Should be Empty:

Personal Information

Educational History

Camp Experience & Qualifications

Employment History

Safe Environment and Pastoral Care

Legal Questions

Short Answer Questions

Short Answer Questions

References

BCI/FBI Background Check

Protecting God's Children

Legal Agreements