2023 Youth Camp - Staff Application

Staff Application

2023 Midlands Region Church of God Youth Camp
Full Legal Name*

First NameLast Name
Preferred Name

First NameLast Name
Phone Number*
Please enter a valid phone number.
Gender*

MaleFemale
Email*
This is the email address we will use to send any youth camp related information to
T-Shirt Size
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Have you lived at this address longer than 2 years?*

YesNo
If your answer was no, please list your previous address

Street Address

Street Address Line 2

CityState

Zip Code
Birth Date*

MonthDayYear
Date
Age
Present Occupation
Employer
Drivers License #
State
Social Security Number*
Needed for Background Check
Today

MonthDayYear
Date
Age - days
Do you have any health problems or physical limitations?*

YesNo
If yes, please explain:
List any allergies or medications you may be taking:
In case of an accident or a serious illness, you have my permission to secure proper medical treatment. (If under 18, parental signature is required)
Signature*

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Staff Acknowledgement
I pledge to abide by all worker guidelines in both action and attitude, and dedicate yourself to the success of camp.*

YesNo
I understand that the Camp Insurance Policy provides secondary coverage, and I provide primary coverage. I accept financial responsibility for any medical costs beyond the limits of the camp policy.*

YesNo
I will be present and on time for Worker's Orientation at 10:00 am the day camp begins. I understand that campers are not to arrive before check-in at 1:00 pm.*

YesNo
I have read and answered all the questions. I understand the importance of each statement.
Signature*

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Statement of Reservation
While no one is rejected to work or attend Church of God Youth Camp based on race, color, or creed, the Regional Director of Youth and Discipleship does reserve the right to accept or reject an application for volunteer work at Church of God Youth Camps after review of the said application reveals that the services of the applicant would or would not be in the best interest and success of the camp.
Applicant's Statement

The information in this application is correct to the best of my knowledge. I authorize any references listed in this application to give you any information (including opinions) that they may have regarding my character or fitness for children or youth work. In consideration of the receipt and evaluation of this application by the Church of God, 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 damage 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. Should my application be accepted, I agree to be bound by the Bylaws and policies of the Church of God and to refrain from unscriptural conduct in the performance of my services on behalf of the church.
I further state that I HAVE CAREFULLY READ THE PRECEDING RELEASE AND KNOW THE CONTENTS THEREOF, AND I SIGN THIS RELEASE AS MY FREE ACT. This is a legally binding agreement which I have read and understand.
Signature*

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Staff Application

Contact Information in Case of Emergency

Staff Acknowledgement

Addendum to Youth Camp Staff Application