Application and Release Form for Employees
Please fill out this form as accurately as possible. If you do not believe that a response is applicable, put “not applicable” in the blank.
Personal Information
Name
*
Maiden Name
First Name
Middle Name
Last Name
Birth Date
*
January
February
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1931
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1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Gender
*
Please Select
Male
Female
N/A
Age
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
example@example.com
Mobile Number
*
Height
*
Weight
*
T-Shirt Size
*
Please Select
Small
Medium
Large
X-Large
XX-Large
XXX-Large
XXXX-Large
List all of your social media handles:
*
Date of Last Tetanus:
*
-
Month
-
Day
Year
Date
Marital Status
*
Spouse’s Name (if not applicable, put N/A in both boxes)
*
First Name
Last Name
Spouse’s Phone Number
Please enter a valid phone number.
Please list any and all chronic conditions you may have:
*
Is there any health related reason that would prevent you from effectively working in an active camp environment or cause potential harm to our campers?
*
Yes
No
If yes, please explain
*
Please list any medications and dosages you are currently taking
*
Food/ Drug Allergies
*
Health Insurance Carrier/ Policy #
*
Hospital Preference
*
Physician’s Name
Dr.
PA
NP
Prefix
First Name
Last Name
Physician’s Phone Number
Please enter a valid phone number.
Emergency Contact
*
First Name
Last Name
Contact’s Phone Number
*
Please enter a valid phone number.
Position Applying for
*
Please Select
Camp Counselor
Rec Staff
Camp Cook
Service and Safety Coordinator
Date Available
*
-
Month
-
Day
Year
Date
Length of Commitment
*
Employment History
List your current job first or most recent job if you are currently unemployed and then all others in reverse chronological order. Please list ALL former employment.
Employer - Supervisor - Dates of Employment - City - State - Phone Number
*
May we contact your current supervisor?
*
Yes
No
If no, please explain why
*
Education
What High School did you attend?
*
When did you attend?
*
Did you graduate?
*
Yes
No
When did you graduate?
*
-
Month
-
Day
Year
Date
Have you attended a college or university?
*
Yes
No
Name of School
*
Years attended
*
Did you graduate?
*
Yes
No
Degree Recieved
*
Please describe below any skills, training, qualifications you possess which you believe would assist CrossView in its operation:
*
Are you CPR and/or First Aid Certified?
*
Yes
No
Expiration of Certification
-
Month
-
Day
Year
Date
Are you Lifeguard Certified?
*
Yes
No
Expiration of Certification
-
Month
-
Day
Year
Date
Are you able to lead worship?
*
Yes
No
Instrument(s)
*
Spiritual Life
What church/fellowship are you a member of?
*
How long have you attended that church?
*
Pastor's Name
*
First Name
Last Name
How often do you attend church?
*
Did/do you work with children at your church?
*
Yes
No
If you did/ do work with children there, describe what you did/do:
*
Please list any previous church service including name of church, full address, whether the position was volunteer or paid, and approximate dates of the service:
*
Do you consider yourself to be a positive role model for others?
*
Yes
No
Please explain why:
*
Please explain salvation as you understand it:
*
Have you accepted Jesus Christ as your Lord and Savior?
*
Yes
No
When?
*
-
Month
-
Day
Year
Date
Have you ever led another person to Christ?
*
Yes
No
Are you comfortable sharing the Gospel?
*
Yes
No
If no, why not?
*
Do you have personal "quiet time" or alone time with God on a regular basis?
*
Yes
No
Are you struggling with any addictions (self-harm, pornography, drugs, alcohol, etc)?
*
Yes
No
If yes, please explain
*
Personal Integrity/ Criminal History
Please provide the names and phone numbers of three personal references not related to you:
*
Is there any reason, including those that are physical or mental health related, that might keep you from effectively working with children or that might cause a child potential harm?
*
Yes
No
Have you ever been charged with, indicted for, or plead guilty for a crime?
*
Yes
No
Have you ever been charged with, indicted for, or plead guilty to an action prohibited by the Texas Family Code, or a similar code in any state?
*
Yes
No
If "yes" to any of the above 3 questions, please explain:
*
If you've ever been known by any other names please list them below:
*
Are you willing to be fingerprinted and background checked by a national agency?
*
Yes
No
If no, why not?
*
Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
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