COUNSELOR/STAFF APPLICATION

Church Phone: 603-483-2272

Director: Lisa Lacombe, 603-748-2159

July 27-August 1, 2025

Instructions: All information is held strictly confidential. This form must be completely filled out. The information is vital to your acceptance and possible placement as a counselor.

Please attach a photo of yourself.

Date

Name

First NameLast Name

Birthdate

Date

Sex

MaleFemale

Age

Marital Status

Street

City

State

Zip

Occupation

Name of Employer

Number of years

How long have you lived in NH?

Number of years

Number of months

If you have lived in NH for less than one year, list your complete addresses for the last five years:

Email Address

example@example.com

Home phone

Cell Phone

Emergency Contact

Relationship

Phone

T-Shirt Size

Do you have certification in the following?

Do you have previous training or background in dealing with abused, neglected or abandoned children?

NoYes

If you answered yes to the previous question, in what way?

Were you a victim of abuse, neglect or abandonment as a minor?

NOYESYes, but I would prefer to discuss this in person.

If you answered yes above, please clarify:

Please describe why you wish to be a counselor for abused kids:

Do you have any medical conditions?

NOYES

If yes, please describe:

Do you take any medications?

NOYES

If yes, please list medicine, reason, and any side effects.

Have you had any serious illness or injuries in the last three years?

NOYES

If yes, please list:

Have you any physical handicaps or conditions preventing you from performing any type of activity?

NOYES

If yes, please list:

High School Name

Date of Graduation

Date

College

Major

Date of Graduation

Date

Other Education

Major

Date of Graduation

Date

Personal References: (not former employers or relatives)

Name

Address

Phone

Name

Address

Phone

Name

Address

Phone

Have you committed your life to Jesus Christ?

NOYES

If yes, where and when:

What church do you presently attend and how long have you attended this church (number of years/months)?

Pastor's Name:

Church Phone #

Do you have any previous experience working with children? If yes, please describe.

Do you have any previous experience working with abused children? If yes, please describe.

Do you feel you could lead a 15-minute devotion with your campers with material we provide?

YESNO

Please indicate which of these words you believe accurately describe you: timid, gentle, impatient, modest, nervous, loving, tactful, mature, sarcastic, patient, angry, deliberate, congenial, compassionate, stubborn, kind, studious, selfish, secure, considerate, abrasive, trustworthy, motivated, verbal, organized, impulsive, intelligent, insecure, relaxed.

List below, five strengths and five weaknesses you have in working with children (please be specific): Strengths

Weaknesses:

I would prefer my campers to be

Have you ever been arrested for a criminal offense?

NoYes

Have you ever been convicted of or plead guilty to a crime?

NoYes

Have you ever been arrested for sexual misconduct?

NoYes

Have you ever been convicted or plead guilty to sexual misconduct?

NoYes

Have you ever taken drugs other than prescription drugs?

NoYes

Do you currently use tobacco?

NoYes

Do you currently use alcohol?

NoYes

Do you currently use drugs?

NoYes

If you answered yes to any of the above, please explain.

Applicant's Statement

The information contained in this application is correct to the best of my knowledge. I authorize any references orchurches listed in this application to give you any information (including opinions) that they may have regarding my character and fitness for children or youth work. In consideration of the receipt and evaluation of this application by Tower Hill Church, I hereby release any individual, church, youth organization, charity, employer reference, or any other person or organization, including record custodians, both collectively and individually from any and all liability for damages of whatever kind or nature which may at any time result to me, my heirs, or family, on account of compliance or any attempts to comply. with this authorization. I waive any right that I may have to inspect any information provided about me by any person or organization identified by me in this application.

I further state that I have carefully read the foregoing release and know the contents thereof and I sign this release as my own free act. This is a legally binding agreement which I have read and understand.

Please be advised that a criminal history check will be requested as authorized by state law.

Print Name

Signature

Date

Witness Name

Witness Signature

Date

Anything else you would like to add:

Please verify that you are human*

COUNSELOR/STAFF APPLICATION

MEDICAL HISTORY

RECORD OF EDUCATION

PERSONAL PROFILE