Indiana Youth Camp Volunteer Application

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Indiana Youth Camp Volunteer Application
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Driver's License# *
State that issued Driver's license*
Former Names
Age *
Date of Birth*

MonthDayYear
Date
Birth Place*
SSN (for background check)*
Gender*
Height
Weight
Eye Color
Married or Single?*
What is your T-Shirt size?
Camp Shirts Cost $15 before or at registration
I hereby consent for the Church of God Youth and Discipleship Director of the state of Indiana to seek from local law enforcement agencies any information which pertains to any record of conviction on its files or in any criminal file or in any criminal file maintained on me whether local, state, national, or international. I hereby release any police department from any and all liability resulting from such disclosure.
Signature*

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Youth Camp You Wish to Work*

Teen Camp (Ages 12-18) June 30th-July 4thKids Camp (Ages 6-12) June 30th-July 4th
Workers Requirements:

Must be at least 19 years old

Must be a regular attendee of your local church

Must be saved and preferably baptized in the Holy Ghost

Must submit a completed Youth Camp Staff Application

Must have the Youth Camp 2024 Pastoral Endorsement submitted by your pastor

All Head Cabin Leaders must be at least 21 years old and baptized in the Holy Ghost
Positions Desired ( selecting one or more of the following is not a guarantee of placement-it is simply expressing an interest.*

Cabin LeaderCanteen/Camp StoreSecurity/Night WatchmanRecreationNurse/Medical StaffHospitality/R &RKitchen StaffNightwatchWorship TeamGroundsRegistrationR & ROther
Children Under Camp Age

Due to limited space, cost-efficiency, and to allow each staff member to fully devote their time and energy to their area of responsibility, we are unable to accommodate children under camp age (under 6 years old). For this reason, prior to your arrival at camp, please make other arrangements for the care of your child(ren) for the duration of camp. Thank you for your cooperation and understanding in this matter.
Personal info and Background
Have you ever been charged, arrested convicted of, or pleaded guilty to any crime?*

YesNo
If yes, would you be willing to discuss this matter with a pastor or ministry leader?*

YesNo
Have you ever been accused, charged , or alleged to have committed any act of neglecting, abusing, or molesting a child or youth?*

YesNo
If yes, would you be willing to discuss this matter with a pastor or ministry leader?*

YesNo
Have you ever been a victim of abuse (verbal, physical, emotional, or sexual)?*

YesNo
If you prefer, you may discuss this answer with a pastor or ministry leader. Answering "Yes" or leaving it unanswered would not automatically disqualify you from the privilege of working in any ministry capacity. However, you may be asked to clarify your response.
Have you ever been involved in homosexual activites?*

YesNo
If yes, would you be willing to discuss this matter with a pastor or ministry leader?*

YesNo
Have you ever been accused, charged or alleged to have committed a theft?*

YesNo
If yes, would you be willing to discuss this matter with a pastor or ministry leader?*

YesNo
Are you addicted to prescription drugs?*

YesNo
Do you use tobacco in any form?*

YesNo
Do you drink alcoholic beverages, including social drinking?*

YesNo
Do you take illegal drugs?*

YesNo
Do you have problems sleeping?*

YesNo
Do you have reoccuring nightmares or sleep disturbances*

YesNo
Do you have a history of using pornographic materials?*

YesNo
Have you been charged with moving traffic violations within the last five (5) years?*

YesNo
Has your driver's license ever been revoked or suspended?*

YesNo
If so, when and why?
Are you presently employed?*

YesNo
If yes employed, where? Job Title/Description? How long?
May we contact your employer?*

YesNo
Name of supervisor*

First NameLast Name
Phone Number of supervisor*
Please enter a valid phone number.
List any physical limitations that need to be considered in your placement, if accepted:*
Are you presently under a doctor's care for any aliments?*

YesNo
If yes to previous question please explain
List any medications
Reasons for medications?
Allergies and Reactions
Do you carry any personal medical insurance?*

YesNo
Insurance Company Name *
Insurance Company Policy #*
Insurance Group #*
List any preauthorization requirements for Insurance:
Physician's Name*
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
The answers to the above questions are correct to the best of my knowledge and ability.

Around the clock medical care is provided. Secondary insurance is available for those accidents which sometimes occur to our staff and campers. I understand that my insurance is primary. I accept any and all medical costs. In case of an acident or serious illness, you have my permission to secure the proper medical treatment.
Signature*

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Date*

MonthDayYear
Date
Thank you for your assistance in all these matters. Please note that all information provided will be kept strictly confidential.
Cabin Leader Info
Will your child be a camper at the same aged camp you will work?

YesNo
If yes, do you want your child to be in your cabin?

YesNo
Will students from your church be at the same aged camp you will work?

YesNo
If yes, should they be placed in your cabin?

YesNo
Personal References
Reference #1 Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Reference #2 Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Statement Of Reservation

While no one is rejected to work or attend Church of God youth camps on the basis of race, color, or creed, the State Youth and Discipleship Director and State Youth and Discipleship Board does reserve the right to accept or reject any application for Volunteer work at Church of God youth camps if after the reviewing of said application reveals that the services of the applicant would or would not be in the bestt interest and success of the camp.
Applicant's Statement

The information contained in this application is correct to the best of my knowledge. I authorize any references or churches listed in this application to give you any information (including opinons) that they have regarding my character and fitness for youth camp work. In consideration of the receipt and evaluation of this application by the Church of God, I hereby release to 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 this 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 have to inspect information provided about me by any person or organization identified by me in this application.

Should my application be accepted, I agree to be bound by the bylaws and policies of the Church of God and to refrain from any unscriptural conduct in the performance of my services on behalf of the church. I also agree to participation in the Mandatory training and enhancement programs (on the first day of each Youth Camp) provided by the Indiana Youth and Discipleship Director's office in preparation of my participation. Furthermore, I will not leave camp until my responsibilites are completed on the last day of camp.

I have carefully read the foregoing release and know the contents thereof and I sign this release on my own free act. This is a legally binding agreement which I have read and understand.
Applicant's Signature *

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Date*

MonthDayYear
Date
Witness Signature*

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Date*

MonthDayYear
Date
Have you spoken to your lead pastor about volunteering at Youth Camp and do they give their approval to work camp?*

Yes, I have spoken to my lead pastorNo, I have not spoken to my lead pastorYes, they gave their approval for me to volunteerNo, they have not given their approval for me to volunteer
Who is your lead pastor? *
What is your lead pastor's email? *
Should be Empty:

Indiana Youth Camp Volunteer Application

Personal info and Background

Cabin Leader Info

Personal References