Personal Information
Name
*
First Name
Middle Initial
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Emergency Contact
Primary Contact Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relation to you
*
Please Select
Mother
Father
Guardian
Aunt
Uncle
Secondary Contact Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relation to you
Please Select
Mother
Father
Guardian
Aunt
Uncle
Friend
Pastor
Pastor's Wife
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Medical and Background Questions
Do you have any allergies? If so, please list.
Do you have any physical limitations, that would make it difficult for you to participate in any camp activities?
*
Background Check: Do you give Northland consent to run a background check on you?
*
Yes
No
Have you ever been convicted of a crime, felony, misdemeanor, forfeiture, or other criminal offense? If “yes,” attach an explanation describing the charge(s), legal jurisdiction, and date.
*
Have you ever been convicted of an offense involving a minor, or endangering the welfare of a child such as child abuse, child neglect, etc. or an offense against a person, such as assault? If “yes,” attach an explanation describing the charge(s), legal jurisdiction, and date.
*
Is there anything which prevents you from legally working in the United States? If “yes,” provide an explanation.
*
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3 Week Recruit Questions
Salvation Testimony
*
Why do you want to be a part of the 3 Week Recruit Program?
*
Which session would you like to attend?
*
Please Select
Session 1: June 16 – July 5
Session 2: July 7 – July 26
Pastoral Reference Name (does not matter if you are related)
*
First Name
Last Name
Pastoral Refernce Email
*
example@example.com
Pastoral Reference Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What skills do you have?
*
mowing
weeding
vacuuming
cleaning bathrooms
mopping
food prep
dish washing
maintenance
small engine repair
working with chainsaws
heavy equipment training
barista experience
fast food experience
lifeguard certification
AED/First aid certifications
List other skills that you might have, write a bit about what you have done before, and what you have experience with.
*
Submit
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