First Name:

Last Name:

E-Mail:

Phone:

Street:

City:

State or province:

Postal/Zip Code:

Birth Month

Select One
January
February
March
April
May
June
July
August
September
October
November
December

Day

Year

Marital Status
Single
Married
Divorced
Widowed

Name of the church of which you are a member

Does your pastor recommend you for this ministry (please have your pastor send an email to the dean of your week confirming this)?
Y
N

Do you have any experience working with minors (those under age 18) in church settings (such as Sunday School teaching, camp work, youth work, Christian school etc.)?
Y
N

If yes, please provide location and name(s) of church(es), approximate dates served, and areas of service below.

Do you currently drink alcoholic beverages (even occasionally)?
Y
N

Do you use any illegal drugs?
Y
N

Have you ever been treated for chemical or alcohol dependency?
Y
N

Have you ever been treated for mental or emotional problems?
Y
N

Have you ever been arrested?
Y
N

Have you ever been convicted of a crime other than a traffic violation?
Y
N

Have you ever been convicted of any type of sexual, physical, or child abuse?
Y
N

If the answer to any of the previous questions is yes, please provide further details below:

By providing my initials, I affirm that the above information is true and complete to the best of my knowledge. I agree to abide by the camp code of ethics and the staff covenant. I understand that any misstatement or omission of information could result in my termination from that ministry. I hereby release all parties including Camp Shiloh, from all liability for any statements or information provided. All information given will be held in strictest confidence. This information will be made available to camp officers, deans, and law enforcement officials upon request.

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