Name
Mailing Address
City
State
Zip Code
Home Phone Number (With Area Code)
Work Phone Number (With Area Code)
Cell Phone (With Area Code)
Email Address
Date of Birth
Sex Please select: Male Female
Marital Status Please select: Married Single
In case of emergency, please notify:
Telephone Number of Person to be Notified
Which camp do you wish to minister? Please select: Middle School (6/15-20) High School (6/8-13)
Name of Your Church
Are you a member of your church? Yes No
Size of Group Your Anticipate to Bring
Legal Question #1: Have you even been arrested for or charged with a sexual offense related to children, or a crime of violence? Yes No
Legal Questions #2: Have you ever been reported to a social services agency, law enforcement authority, child abuse registry, or similar organization regarding abuse or misconduct involving children? Yes No
Legal Questions #3: Have you ever been subjected to expulsion, reprimand, or other discipline by a church, denomination, or other religious organization? Yes No
Legal Question #4: Have you ever been the subject of a civil lawsuit involving sexual misconduct, sexual harassment, or other immoral behavior or conduct involving adults or children? Yes No
Legal Question #5: Have you even been the subject of any disciplinary action, transfer, or dismissal or been named as a defendent in a civil lawsuit as a result of an accident or mishap involving children? Yes No
If your answer was "Yes" to any of the previous legal questions, for each positive response, please provide the following information: 1) Date and complete description of the circumstance 2) Name and address of the church, employer, or other organization
By typing your full name in the box below, you are signifying that you have read all of the counselor information, have filled out the application and the legal portion of the questionnaire, and that you understand your responsibility as a counselor.
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