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In our society it is incumbent upon us to: "know those that labor among you.

" Therefore, we take


precautionary steps to insure the well-being of our campers and the integrity of Church of God Youth Camp in
Ohio. Your understanding and cooperation is greatly appreciated.

SCREENING FORM & WORKER APPLICATION

Release for Criminal Records Check

Staff Applications must be postmarked by May 28th.

I hereby consent for the State Director's office to seek from local law enforcement any information which pertains to any record of conviction
contained in its files or in any criminal file maintained on me whether local, state, or national. I hereby release the Police Department from any and
all liability resulting from such disclosure.

Please Print

Name: _____________________________________________________________________________________
First

Signature: _____________________________________________ Date _________________

Middle

Last

(Maiden)

Address: ___________________________________________________________________________________

Applicants Statement

City: ______________________________________________________ State: ________ Zip: _______________

The information contained in this application is correct to the best of my knowledge. I authorize any references of churches listed in this application
to give you any information (including opinions) that they may have regarding my character and fitness for youth camp work. In consideration of
the receipt and evaluation of this application by the Church of God, I hereby release to any individual, church, youth organization, charity, employer,
reference, or any other person or organization, including record custodians, both collectively and individually, from any and all liability for damages
of whatever kind or nature which may at this time result to me, my heirs or family, on account of compliance or any attempts to comply with this
authorization. I waive any right that I may have to inspect any information provided about me by any person or organization identified by me in this
application.
Should my application be accepted, I agree to be bound by the bylaws and policies of the Church of God and to refrain from any unscriptural
conduct in the performance of my services on behalf of the church. I also agree to participate in the training and enhancement provided by the
State Director's office in preparation of my participation this summer. (This training will begin Sunday evening prior to the first week of camp and is
MANDATORY for all workers!)
In the event of an accident or serious illness, I hereby give my consent for diagnosis or treatment to be rendered to me from qualified medical
personnel, both on and off campus, should such action be necessary in the opinion of camp officials.

How long have you lived at this address? ____________ If less than two years, give previous address below.

Previous Address: ____________________________________________________________________________


City:________________________________________________________ State:_________ Zip:______________
Sex:

Date of Birth: _______/_______/_________ Social Security #: _________-_______-_________

Phone (Cell): _______/_______/_______________ Phone (Home): _______/________/____________________


E-Mail: _________________________________________ Phone (Work): _______/________/_______________
Local Church: ___________________________________________ Pastor: _____________________________
REQUIREMENTS FOR YOUTH CAMP WORKERS

I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THIS RELEASE AS
MY OWN FREE ACT. This is a legally binding agreement which I have read and understand.

_________________________________

______________________________

________________________

Applicant's Signature

Witness Signature

Date

*PLEASE ENCLOSE A PASSPORT SIZE PHOTO, OR PICTURE I.D., WITH THIS APPLICATION*
NO APPLICANT CAN BE ACCEPTED WITHOUT THE COMPLETED SIGNATURE ENDORSEMENT FORM OF THEIR LOCAL
CHURCH PASTOR. PLEASE HAVE YOUR PASTOR FILL OUT THE FORM AND SEND IT IMMEDIATELY.

If you are applying to be a CABIN LEADER - Please Respond

Must be at least 15 years of age Cabin Leaders must be 18 + Must be a regular attendee of a local church Endorsement Form completed and
signed by your pastor Complete and submit the Screening Form and Application.

PositionsForWhichYouMayApply
ToworkincamponemustbeacommittedChristianatleast15yearsofage.SeniorCampworkersmustbeatleast19.Inyoungercamps,alimited
numberofteenagers,ages1518maybeacceptedprovidingtheyareneeded.Prioritywillbegiventoadultworkers.NoworkershouldreporttocampwithoutcontactfromtheStateYouthDepartment.
WHAT IS A CABIN LEADER?
A Cabin Leader accepts the challenge to care for a group of campers. A Cabin Leader must be patient, gentle, fair, firm, consistent, and able to lead.
Each Cabin Leader may select an assistant leader of their choice, provided he/she completes a worker's application and is qualified (workers under
age eighteen may be allowed to work as an Assistant Cabin Leader).
WHAT IS A STAFF MEMBER?
A staff member may request a particular assignment such as night security, kitchen staff, etc. However, it is important to understand our youth camp
"team" approach. Every staff member must be willing to accept daily assignments according to camp needs. Staff members often assume additional
duties and are called upon to assist in other areas.

Please Check the Camp(s) You Would Like to Work

CIRCLE YES or NO - Answer A, B, C, D

A. Will your child be a camper the same week you will work?
If yes, do you want your child to be in your cabin?
C. Do you suggest a qualified person to assist you?

Yes

No

B. Will campers from your church be in your camp? Yes

No

Yes

No

If yes, should they be placed in your cabin? Yes

No

Yes

No

D. If yes to C, who do you suggest? _____________________

Mail All Applications To:

Questions? Contact our Youth & Discipleship Department at


330.668.9995 or lindy@ohiocog.com

Ohio Church of God State Office


Attn: Youth Camp 2012
211 N. Cleveland-Massillon Road
Akron, Ohio 44333
Office: 330.668.9995 I Fax: 330.670.1335
www.ohiocog.com

OHIO YOUTH CAMP 2012

FOR OFFICE USE ONLY


Region:

________ Camp(s):

__________
__________

Pastors Endorsement: ________ _______________________


App Entered By:

________
________
________
________

NORTHERN REGION
Senior High / June 25-29 (Ages 14-17)
Kids Camp / July 1-4 (Ages 7-10)
Intermediate / July 4-7 (Ages 11-14)

________
________
________

Please Number the Jobs by Order of Preference:


____ Cabin Leader
_____ Assistant Cabin Leader
_____ Recreation Staff
_____ Clean Up/Custodial _____ Certified Lifeguard
_____ Camp Store
____ Kitchen Food Prep Worker (Northern Region Only) ______ Cafeteria Clean Up _____ Canteen Worker
____ Registered Nurse
_____ Nurses' Assistant
______ Night Watchman
_____ *Crafts
_____ *Drama ____ *Bible Study Leader
____ *Music Leader
*Other (Specify) __________________ (Note: The asterisks (*) on staff Job Preference indicates for they are for electives.)

WhilenooneisrejectedtoworkorattendChurchofGodyouthcamponthebasisofrace,color,orcreed,thestatedirectorofyouthandChristianeducationandcampofficialsreservetherightto

Southern or Northern Assignment:

Date Postmarked:

SOUTHERN REGION
Senior High / June 11-15 (Ages 15-17)
Junior High / June 18-22 (Ages 12-14)
Kids Alive / June 25-29 (Ages 10-12)
Adventure Time / July 2-5 (Ages 7-9)

________ _______________________

acceptorrejectanyapplicationforvolunteerworkatcampsafterreviewofsaidapplicationrevealsthattheservicesoftheapplicantwouldorwouldnotbeinthebestinterestandsuccessofthe
camp.Thisapplicationisgiveneveryconsideration,butitsreceiptdoesnotimplythattheapplicanthasbeenacceptedforcampworker.Applicantsareacceptedona"trialbasis"andifthe
applicant/workerisnotadaptabletotheassignmentandcannotbereassigned,orthatinformationgivenhasbeenmisrepresented,theacceptanceofthisapplicationcanbeterminatedwithout
othercauseornotice.Inaddition,investigationwillbemadeastotheapplicantscharacter,generalreputation,personalcharacteristics,andadaptabilitytotheparticularpositiontobeassigned.All
applicantsarerequiredtoundergotraining/orientationprovidedbytheSateYouthandCEdirector'sofficeandunderthesupervisionoftheStateYouthandCEboard.Applicantsarenotrequired
toprovideinformationwhichisprohibitedbyFederal,State,orlocallaw.

PERSONAL INFORMATION:

CHURCH HISTORY, PRIOR YOUTH WORK, EDUCATIONAL & SPIRITUAL STATUS:


Name of the pastor and name of the church of which you are a regular attender:
_____________________________________________________________________________________________________________

Place of Birth: __________________________________________________ Married: ______ Single: _______


City

County

Name of the pastor and name of the church of which you are a member:
______________________________________________________________________________________________________________

State

Height: ___________ Weight: __________ Hair: _____________ Eyes: ___________ Race: _______________
Have you ever been convicted of or pleaded guilty to a sexual assault, sexual abuse or child abuse?

Yes _____ No _____

Have you ever been convicted of or pleaded guilty to a felony?

Yes _____ No _____

Have you ever been charged, arrested, convicted of, or pleaded guilty to any crime?

Yes _____ No _____

List (name) other churches you have attended regularly during the past five years: _______________________________________
List all previous church work involving youth (list each organization's name / address, type of work performed, and dates) :
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
List any gifts, training, education, or other factors which have prepared you for work in youth camp.
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________

Have you ever been accused, charged, or alleged to have committed any act of
neglecting, abusing, or molesting a child or youth?

Yes _____ No _____

Have you ever been a victim of abuse (verbal, physical, sexual)?

Yes _____ No _____

Why did you decide to work at camp this year?


______________________________________________________________________________________________________________
______________________________________________________________________________________________________________

You may discuss the answers to the previous questions with a pastor or ministry leader. Answering Yes or leaving it
unanswered will not automatically disqualify you from the privilege of working. You may be asked to clarify your response.
Have you ever been involved in homosexual activity?

Yes _____ No _____

Have you ever been accused, charged or alleged to have committed a theft?

Yes _____ No _____

What parts of the camp position/work do you most look forward to?
______________________________________________________________________________________________________________
Have you previously worked in Ohio Youth Camps? What year(s) ? Doing what?
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________

(If answered YES to any of the above questions and would like to give us a clearer picture of your background / history, please
explain below (attach a separate page if necessary). If answered YES to any of the above questions, would you be willing to
discuss this matter with a pastor or ministry leader? __________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________

EDUCATIONAL BACKGROUND:

(Please check highest year completed in appropriate space)

Junior High (Grades 7-9): ________ High School (Grades 10-12): ________ College (1-4): _________ Graduate School: _________

SPIRITUAL STATUS: (Fill out all applicable spaces)


HOW LONG have you been: Saved: _________________ Baptized In Water: _________________Sanctified: _________________
Filled with the Baptism of the Holy Ghost: _________________________ Church Member: ________________________________

Are you addicted to prescription drugs?

Yes _____ No _____

Do you use tobacco in any form?

Yes _____ No _____

Do you drink alcoholic beverages?

Yes _____ No _____

PERSONAL REFERENCES

Do you take illegal drugs?

Yes _____ No _____

Do you have problems sleeping?

Yes _____ No _____

Do you have recurring nightmares or sleep disturbances?

Yes _____ No _____

Name _______________________________________
Address _____________________________________
_____________________________________________
Telephone (
) _______________________________

Do you have a history of use of pornographic materials?

Yes _____ No _____

Have you ever been charged with moving traffic violations?

Yes _____ No _____

Has your drivers license ever been revoked or suspended?

Yes _____ No _____

Do you have a current driver's license? (some form of picture ID may be required)

Yes _____ No _____

(not employees / relatives)


Name ____________________________________________
Address __________________________________________
__________________________________________________
Telephone (
) __________________________________

Medical / Insurance Information


List any physical limitations you feel need to be considered in your placement, if accepted:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Are you presently under a doctor's care for any ailment?: _______________________ Any medications?: ____________________
Reason for Medication ________________________________________ Allergies/reactions: ________________________________
Do you have personal medical insurance? YES NO What company? ______________________________________________
Policy #__________________________________________ Pre-Authorization required? _____________________________________
Doctor's Name & Phone Number _________________________________________________________________________

(List your DL# and state) __________________________________________________________________________________________


Are you presently employed? If so, where?: ________________________________________ Phone:_______/________/____________

If you are under the age of 18, please have your parent sign this medical release below:

Job Description: ________________________________________________________________ How long?: ________________________


May we contact?:

YES

NO

In the event my child __________________________ needs emergency medical attention, I hereby give my consent for the officials of
the camp to seek such medical assistance. I further understand that the camp will make every attempt to notify me of such action as
soon as possible.

Supervisor's Name: ___________________________________________________________________

*PLEASE ENCLOSE A PASSPORT SIZE PHOTO, OR PICTURE I.D., WITH THIS APPLICATION*

Parents Signature: _________________________________________________________


Ohio Church of God State Office - 211 N. Cleveland-Massillon, OH 44333 - O: 330.668.9995 - F: 330.670.1335 - www.Facebook.com/OhioCOGYouthCamp

Date ________________________________

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