I would like to apply to be on staff at:       select only one Camp Impact Camp Cornerstone Zenith

I am applying to for the position of:       select only one Counselor Medical Staff Support Staff Security Staff

Last Name:

First Name:      Gender:       - Male Female

Age:    Birthday:   Phone:

Church:

Email:       

Re-type Email:      

Mailing Address:

City:    State:   Zip:

Child/Youth  Minister:

Child/Youth Minister's Email:

Have you served on this camp staff in previous years? Select One Yes No

School Level & College:       select one 2008 Junior - High School 2008 Senior High School Parent Adult Youth Worker OC Student ACU Student York College Student LCU Student Harding Student Aggies For Christ Student Other College: student

References  (3 required including valid email addresses)

Reference 1 Name:

Relationship:

Reference 1 Email:

Reference 2 Name:

Relationship:

Reference 2 Email:

Reference 3 Name:

Relationship:

Reference 3 Email:

Are you a previous camper?  --select one--- No Yes

Are you CPR certified?  ---select one--- No Yes     Certified Lifeguard? No Yes

(Medical Staff Applicants):  You are a: - RN LPN MD Paramedic Other

Shirt Size: select one Small Medium Large XL XXL   

Are you serving as a summer youth/children ministry intern for the children/youth minister listed above:  NO YES

Driver's Lic. Number:   State Issued:

Have you ever been convicted of a felony?       choose one No Yes

Are there any physical handicaps that might prevent you from serving in this capacity?        select one No Yes

Did you serve on this camp staff in 2007?  Yes  No

I hereby agree to allow CampOC and/or it's assigned agents to check above references and will provide additional references as needed.  I also agree to allow CampOC and/or it's assigned agents to initiate and conduct a background check with the provided information.  I hereby agree that all information provided on this form is accurate and correct.  I agree that if I am selected for this service, I will conduct myself in a manner that reflects positive values, morals and faith.  I also understand that my application can be revolted and/or I can be dismissed from this role at any time by the Camp Directors without explanation given. 

If you agree to the above statement type your name here:

Emergency Contact:

Emergency Contact Phone Number:

When this form is complete please click SUBMIT button below: