Counselor & Staff Application

NORTH/NW DISTRICT JULY 15-19, 2013

THIS IS A LEGAL DOCUMENT **PLEASE PRINT CLEARLY**

Full legal name:___________________________ ____________________________ ___________________________
Last

First

_______________________________

_______

Preferred Name

Male/Female

Middle

T-Shirt Size ________

Home address:______________________________ City:__________________________ State:______ Zip:___________

Birthdate:___________________ Home phone:(

)__________________ Cell Phone:(

)___________________

Email ____________________________________________________________________
Emergency contact___________________________________________________________________________________
Relationship

Day Phone #

Night Phone #

Name of Employer & Work address:______________________________________________________________________

Church membership: __________________________________ _________________________________ _____________
Name of Church

City

District

Areas of church leadership/involvement:___________________________________________________________________

Expertise/talents you offer to the camp (i.e., instrumental music, vocal, crafts, athletics, small group leadership, etc.):
____________________________________________________________________________________________________
Prior experience working with youth in church or camp setting:________________________________________________
Indicate first responder certifications you have (EMS, CPR, First Aid, etc.)_________________Date certified____________
Date Safe Sanctuary Certified ___________________
Name & telephone # for reference check:_________________________________________________________________
Rank your age level preference (1 is highest):

_____4th/5th

_____ 6th/7th

_____ 8th/9th

____10th 11th/ 12th

Please indicate any emotional, behavioral, or physical disabilities which may require special awareness. Your answer will not
necessarily result in exclusion from camp. This information will be made available to camp coordinator,director, nurse, and
registrar._________________________________________________________________________________________
Date of last Tetanus immunization: _______________.
List any allergies (medications, food, insects,etc.) ___________________________________________________________
List any special conditions, restrictions or medications:________________________________________________________
Physician:____________________________________________ Physician's telephone #: (

)____________________

____________________________________________________________________________________________________
Health Insurance Carrier

Policy #

Phone #

By signing below I am hereby giving permission, in case of emergency, to the physician selected by the camp to hospitalize, secure
proper treatment, and order injection, anesthesia, or surgery in my behalf. Additionally, I have read and understand the Standards
Regarding Conduct which are printed on the reverse side, and I also understand that this youth camp is tobacco free. I hereby state
that all information given on this form is true and correct.
Legal signature:_____________________________________________________ Date:_______________________
State of Texas County of _____________
This instrument was acknowledged before me on the ____day of _________by ____________________________________.

(Notary seal/stamp)

___________________________________________
Notary Publics Signature

Pastor's signature______________________________________________ Date ___________________________

My signature indicates recommendation of applicant for counselor based on personal knowledge of

him/her and their qualifications. My signature also confirms applicant is Conference Safe Sanctuary
Certified & Background Checked.
Registration & participation in Lakeview's programs are the same for everyone without regard to race, color, religion, age, gender,
disability, national origin, or political belief.
(2/13)

BE SURE TO INCLUDE STANDARDS REGARDING CONDUCT FORM