Staff Application Staff Application Form 2022 Step 1 of 2 50% New or Former Staff* New Staff Member Former Staff Member Gender* Male Female Applicant Name* First Middle Last Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth* MM slash DD slash YYYY Occupation Employer / School Email* Temporary or Educational Residence Address (if applicable) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Church of Christ Congregation where you are currently a member* Church Phone Number (with Area Code)*ReferencesNote: You MUST SUBMIT a letter of reference, or the completed reference sheet, from an Elder, preacher, or a person in a leadership position of the Church where you are a member. Please supply two additional references here:Reference 1 Name* Reference 1 Phone (with Area Code)*Reference 1 Position / Relationship* Reference 2 Name* Reference 2 Phone (with Area Code)*Reference 2 Position / Relationship* All staff members must be at least 18 years of age or older and be at least one year out of high school. Experience with Youth Groups Staff Position Applied For: Counselor / Teacher Administration / Support Medical Lifeguard Kitchen (Please mail/provide a copy of any applicable certification/training documents – i.e. Lifeguard, Nurse, EMT, etc.)Additional InformationAdditional Information: Indicate Yes or No for each of the following questions. Any individual who fails to disclose a conviction will be precluded from serving on the staff.Have you ever been convicted of a felony or misdemeanor?* Yes No (If yes, explain below) Have you ever been charged with child neglect or abuse?* Yes No Other than the above, is there any fact or circumstance involving you or your background that would call into question your being entrusted with the supervision, guidance, and care of young people?* Yes No (If yes, explain) Additional InformationAcknowledgement* I understand that: a. The information that I have provided may be verified, if necessary, by contacting persons or organizations named in this application, or by contacting any person or organization that may have information concerning me. I hereby authorize the session director to perform a criminal background and sex offender registry check on me. I hereby release and agree to hold harmless from liability any person or organization that provides information. I also agree to hold harmless Bandina Christian Youth Camp, Inc. and the officers, employees, and volunteers thereof. b. In signing this application, I have received and read the attached Safe Environment Policy information and apply for a volunteer staff position with Bandina Christian Youth Camp, Inc. I agree to comply with the Bylaws and the Policies and Procedures of Bandina Christian Youth Camp, Inc. I affirm that the information I have given on this form is true and correct. I will follow the Safe Environment Guidelines. Bandina Christian Youth Camp – Staff Medical Information FormStaff Member Name* Date of Birth (mm/dd/yyyy):* Gender:* Address* Emergency Notations: This Box For Camp Administration Use OnlyLocation on Campus This Box For Camp Administration Use OnlyEmergency Contact Name* Emergency Contact Home PhoneEmergency Contact Cell Phone*Emergency Contact Work PhoneDo you have medication or food allergies?* Yes No If yes, what? Type of reaction (i.e., rash, difficulty breathing, etc.) Past Medical History – Please answer Yes or No to each. If yes, please explain.Heart Problems* Yes No If yes, please explain Diabetes* Yes No If yes, please explain Kidney or Bladder Problems _* Yes No If yes, please explain Stomach/Intestine/Liver* Yes No If yes, please explain Lung (i.e. asthma, etc.)* Yes No If yes, please explain Thyroid* Yes No If yes, please explain Neurological or Mental* Yes No If yes, please explain Other Have you had surgery within the last year?* Yes No If yes, provide explanationWill you (counselor) have special medicine with you at camp? If yes, please list all daily and as needed medications (prescription and non-prescription) you will/may take at camp.* Yes No NOTE: All medications must be in original containers. All prescription medications must have original pharmacy label on containers with name in order to be dispensed at camp. No medicines can be kept in cabins with campers. If yes, please list all daily and as needed medications (prescription and non-prescription) you will/may take at camp.Name of Medicaton Strength (mg) Time to be Taken Reason for Medication Name of Medicaton Strength (mg) Time to be Taken Reason for Medication Name of Medicaton Strength (mg) Time to be Taken Reason for Medication Name of Medicaton Strength (mg) Time to be Taken Reason for Medication Have you been immunized for the following? (Answer Yes or No for each item.)Measles* Yes No Mumps* Yes No Chicken Pox* Yes No Diphtheria* Yes No Whooping Cough* Yes No Do you currently or have you had a communicable disease within the last six months?* Yes No Consent* *State Regulations require that ALL medication be in original containers, have an original, intact prescription label affixed with the patient’s name, be stored in a secure location not accessible to campers, and can only be dispensed under the direction of the Camp Health Officer (CHO). [see 25 TAC §265.15(l)] Staff Members are required to maintain ALL medications in a secure location not accessible to campers.Consent* I hereby acknowledge and grant permission for the following:*• I am at least 18 years of age. • Pre-existing conditions, injuries or illnesses occurring or existing prior to arrival at the camp will not be covered by camp insurance, and the staff member’s personal insurance is primary and camp insurance is secondary. • The Camp Director, the CHO or other qualified staff may take me to the hospital, to the doctor, or seek other reasonable and appropriate emergency treatment in case of an accident or sickness. • Medical and surgical treatment may be conducted as needed in the judgment of treating physicians. • The medical information provided is intended for the use of camp personnel and any attending medical personnel and will be shared on a limited basis with those needing to know, but will otherwise be maintained as confidential. • Staff members may participate in swimming or water-related activities, but based on the conditions present at the water-front, they may be required to passing a swimming proficiency test administered by a certified lifeguard. Staff Member's Signature*Date* MM slash DD slash YYYY