Adult Volunteer Application

Adult Staff Questionnaire

Thank you for applying to serve at Pleasant Valley Christian Camp! Please answer all questions below.
Application Date *

Month Day Year
Date
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email Address *
Gender: *

Male Female
Birth Date *

Month Day Year
Date
T-Shirt Size (Adult)

XS S M L XL XXL XXXL
At which camp(s) are you interested in serving? *

Winter Kids' Retreat Serve Weekend First Chance Camp Junior Camp Middle School Camp Family Camp Young At Heart Retreat Rental Groups General/off-season
Which position are you interested in? *

Counselor Music/worship Speaker Activities/recreation Camp nurse Lifeguard Kitchen/food service Housekeeping Grounds/maintenance Check-in/office support
Please select any of the following certifications, licenses, or other training you have: *

CPR/first aid Lifeguard certification RN license Food handler's permit None of these
Please select any of the following skills or interests that you have:

Crafts Teaching/preaching Skits/drama Video/photography Guitar Piano Drums/rhythm Singing Leading sports and field games Hiking
Please provide a personal reference who can tell us more about you. List first and last name, phone number, and email address.
Do you consider yourself to be a Christian? Please describe what that means to you.
In the last year, how has God shown up in your life?
In what areas are you seeking to grow in your faith and/or personal development?
In what ways can we be praying for you and encouraging you?
Please provide the name of your pastor and the church you attend. Include a contact phone number. *
Please list any experience you have working with children. Include the positions, organization names, contact names, and phone numbers.
Please list any allergies to food, medications, or environment. *
Please list any medical conditions you would like us to know about. *
Permission to Treat: I hereby give permission to medical personnel to provide me with health care and emergency treatment, including, but not limited to, X-rays, routine tests and treatment and/or hospitalization; and to provide or arrange necessary related transportation. I also agree to the release of any records necessary for treatment, referral, billing or insurance purposes. *

Yes No
Photo Release: I hereby grant permission to be video taped and/or photographed while participating in programs and activities of Pleasant Valley Christian Camp. I Understand that video taping and photographs will be used for educational, training and promotional purposes only. *

Yes No
Screening Questionaire

Because Pleasant Valley Christian Camp desires to protect the children in our care, please answer the following questions. We understand that the answers to these questions may be private and deeply personal and we will protect your privacy.
Why do you want to work with children in this ministry? *
Do you have a preference concerning the age and/or gender of children with whom you work? *
Have you ever physically or sexually abused a child? *

No Yes
Has someone ever accused you of abusing a child? *

No Yes
I authorize Pleasant Valley Christian Camp to contact all individuals, organizations, and references listed on this application form to verify the information I have provided. I agree to release from liability any person or organization that provides information concerning me, including those persons I have listed as references and contacts from my previous work with children. **Please Type your name and today's date to sign your application.** *
Should be Empty:

Adult Staff Questionnaire