Camp Staff Form 2025

Name

First NameMiddle NameLast Name

Birthday

Date

Gender

MaleFemale

Social Security Number*

Other names by which you are known (e.g. maiden name)

First NameLast Name

Spouse's Name

First NameLast Name

Your Child's Name #1

First NameLast Name

Your Child's Age #1

Your Child's Name #2

First NameLast Name

Your Child's Age #2

Your Child's Name #3

First NameLast Name

Your Child's Age #3

Your Child's Name #4

First NameLast Name

Your Child's Age #4

Your Child's Name #5

First NameLast Name

Your Child's Age #5

Your Child's Name #6

First NameLast Name

Your Child's Age #6

Your Child's Name #7

First NameLast Name

Your Child's Age #7

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Please enter a valid phone number.

City

State

Number of Years

City

State

Number of Years

City

State

Number of Years

City

State

Number of Years

City

State

Number of Years

Upload Copy of Driver's License

Driver's License #

State Issued

Name of High School

Graduation Date

Name of College

Graduation Date

Current Certifications

Upload Certificates

Years as a Camper

Camps with Years Attended

Years as Camp Staff

Camp Names, Positions, and Years Served

Employer: Include Name of Employer, Address, Telephone and Dates Employed

Reference 1: Include Name, Relationship, Address, and how long you know this person.

Reference 2: Include Name, Relationship, Address, and how long you know this person.

Reference 3: Include Name, Relationship, Address, and how long you know this person.

Have you previously served at Camp Pineshore?

YesNo

1. Have you ever been convicted of any crime relating in any manner to children and/or your conduct with them?

YesNo

Read this list:

Indecent assault and battery on a child under 14
Indecent assault and battery on a mentally retared person
Indecent assault and battery on a person who has obtained the age of 14
Rape
Rape of a child under 16 with force.
Assault with intent to commit rape
Kidnapping of a child under sixteen with intent to commit rape
Distrubiting and trafficking of narcotics or other controlled substances.
Intent to commit any of the above crimes

2. Have you ever been convicted of any crime including, but not limited to those listed above.

YesNo

3. Have you ever been abjudged liable for civil penalties or damages involving sexual of physical abuse of a children?

YesNo

4. Are you now or have you ever been subject to a court order involving sexual or physical abuse of a minor including, but not limited to domestic order or protection?

YesNo

5. Have you parental rights ever been terminated for reasons including sexual or physical abuse of children?

YesNo

6. Have you ever been convicted of a felony or misdemeanor within the last 5 year?

YesNo

7. Have your parental rights ever been terminated for reasons involving sexual or physical abuse of children?

YesNo

8. Have you ever been convicted of a felony or a misdemeanor within the last 5 years?

YesNo

If you answered yes to any above questions, please explain.

I understand that:

a. Camp Pineshore may deny employment to any person who answers "yes" to any one of the questions numbered 38.
If
hired and the employer later discovers circumstances that would indicate a "yes" answer to any of the above questions,
employment may be terminated immediately.
b. The information provided on this form is subject to verification, which may include a criminal history check and request
from any Central Registry of child abusers.
c. Camp Pineshore may terminate employment or volunteer service of any person if that person is found, regardless of
when discovered, to:
1) have a history of complaints of abuse of a minor;
2) have resigned, been terminated or been asked to resign from a position whether paid or unpaid, due to complaint(s)
of sexual abuse of a minor; and/or
3) have falsified or omitted information in this disclosure statement.
d. Camp Pineshore is required by the Commonwealth of Massachusetts to obtain a criminal offender record information
(CORI) and a Sex Offender Registry (SORI) check for all employees.
e. This disclosure statement must be updated yearly.
f. I verify that all the information I have provided Camp Pineshore is correct. If any of the information is false, I
understand I may be terminated from my position at Camp Pineshore.
g. Unless otherwise stated, my signature permits Camp Pineshore or Messiah

Name

First NameLast Name

Signature

Date

Name of Staff/Volunteer's Guardian, if Minor

First NameLast Name

Guardian's Signature

Date

Camp Staff Form

Children

Address Information

Previous Residence(s) for the last Five Years

Residence

Residence

Residence

Residence

Residence

Driver's License and Automobile Information

Education

High School

College/Vocational School

Certifications

Camp Information

Voluntary Disclosure Statement

Past Employment (Past 5 Years)

References

History

Permission to Obtain a Background Check