Staff Application

Name Email Address
Permanent Address Zip Home Phone
School/Business Address Zip Phone
Date of Birth Age

Name of Church you attend Location
Pastor or Youth Pastor's Name Phone

Condition of Health: Excellent Good Fair Poor Are you taking prescribed medication? Yes No
If yes, please describe:
Do you have any physical limitations which would limit your participation in an active schedule and enviroment?
Yes No If so, please explain:

Have you ever been accused or convicted of:
--------Child abuse? Yes No -------- Sexual Abuse? Yes No -------- A Felony? Yes No
If yes, please explain:
Camp Alkulana reserves the right to, in its sole discretion, conduct (1) a criminal background check and/or (2) an inquiry to the Department of Child Protective Services with regard to any applicant. Any employment or offer of employment is subject to termination or withdrawel at any time based on this information.

Education (Include Major subjects, dates and schools)

Previous Camp Experience - Not necessary, but helpful (Dates/Camp)

Other leadership or teaching experience with children, ages 9 - 14

Past Employment (List all previous work experiences, name of supervisor, and current phone number)

	Dates	Employer	Supervisor	Phone #
1
2
3
4

Please list the names of three adults, other than relatives and classmates who have observed you at work with children and/or peers. Reference forms will be sent to them.

Name Address (include Zip) Phone # Position

1

2

3

Person to be notified in case of illness or accident:
Name Home/Cell Phone Work Phone
Address

How do you occupy your free time?

What kind of impact do you feel a well-run Christian camping experience can have on a child's life?

What contributions do you think you can make at Camp Alkulana?

Briefly describe the part your relationship to Jesus Christ plays in your life.

Are you Willing or Eager to grow in your faith? (Check one) What are you doing now that helps you grow in your faith and/or express your faith?

It is understood that all Camp staff members will be expected to abide by Camp policies and to participate wholeheartedly in the entire camp program.

By clicking the Submit button, I certify that this information is true and agree to abide by Camp policies if I am expected to work on the camp staff. I authorize any reference or supervisor listed in this application to give you any information (including opinions) that they may have regarding my character and fitness for children/youth work.