Staff Application Step 1 of 3 33% 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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. Nurse's InformationHome Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact Name* Emergency Contact Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact Home Phone*Emergency 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. 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 had a tetanus shot within the last six months? Yes No 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 I understand that my health information may need to be shared with camp staff to ensure a safe camp experience. I hereby give permission for the director and/or camp nursing staff to take me to the hospital and/or to see a doctor in case of sickness and/or an accident. I also give authority and consent for medical and surgical treatment as needed in the judgment of treating physicians. I agree the youth camp and its staff will not be held responsible for any accident or sickness incurred. I agree not to bring legal action against Bandina Christian Youth Camp, Inc. I understand that pre-existing conditions, injuries or illnesses will not be covered by camp insurance. I also understand that my personal insurance is primary and camp insurance is secondary. Staff ParticipationThis is how I want to serve during camp. The Board of Directors of Bandina Christian Youth Camp, Inc. requires that all counselors and teachers be members of a congregation of churches of Christ. Tee-shirt size (adult):*SmallMediumLargeX-LargeXX-LargePreferred Service Areas*Please check the following areas according to your areas of interest or ability: I would like to work as a counselor in a cabin with campers. I would like to work in a support role with campers, but not in a cabin with campers. I would like to work in a support role at camp, not directly with campers (kitchen, maintenance, cleaning) Preferred age of campers you prefer to work with:*Counselors must be at least 5 years older than the campers they supervise. Please check all that apply*All counselors also work as either teachers, coaches or in crafts: I would like to work as a morning teacher. I would like to work as a sports coach. I would like to work in crafts. I would like to work in special activities and games. I would like to work in the kitchen as cook. I would like to work in the kitchen as clean up. I would like to work as camp nurse and I have the following license or certificate: I would like to work as a lifeguard and have certification that I will bring with me. Nurse license or certificate: Training & Orientation*The State of Texas requires that all staff be properly trained and oriented for their roles at camp. This training is scheduled for Saturday evening and Sunday morning before camp begins. All staff is required to attend. All staff is expected to be at camp for the entire period, Saturday (July 13) through Saturday (July 20). Each staff person is required to take the Sex Abuse Prevention Course before camp begins (online or in written form). State of Texas regulations require both criminal and sex abuse background checks on camp personnel. I will be at camp from Saturday afternoon, July 10, through Saturday noon, July 17, 2021.Do you have experience as a camp staff member?* Yes No If yes, where? What staff positions have you filled?Do you currently teach a Bible Class?* Yes No If yes, what age group? Please read and confirm:* I will never, under any circumstance, strike a child while at camp. I will not use profanity at camp. If I bring a weapon to camp, I will keep it locked in my vehicle and not allow a camper to see or handle it. Consent* I understand that Bandina Christian Youth Camp does not allow the use of alcoholic drinks, tobacco products, nor any illegal substance. I understand that the use of these agents will result in my immediate dismissal. I understand that I may not use or have in my possession any alcoholic drinks, tobacco products, or illegal drugs/substances.*Consent* I understand that State Regulations require that I turn in all prescription and non-prescription medication to the camp nurse upon my arrival at camp to prevent them from being within the reach of campers staying in my cabin. I understand that the camp nurse will administer my medication to me as needing during the week of camp.*Staff Member's Signature*Date* MM slash DD slash YYYY