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					                          2011 Florida Teen Camp
       Camp Counselor/Additional Staff/Activities Coordinator Application

Please read these important highlights about Camp Counselor/Additional Staff/Activities Coordinator

          Registration deadline is Wednesday, June 1, 2011.
          Remember to attach a copy of your Drivers License or Photo Identification Card.
          Remember to attach a copy of your Health Card.
          Remember to obtain your Ministry Leader’s Reference timely in order to meet the deadline.
          Remember to get approved for the Children’s Ministry if not already.
          Mail your completed application to:
             Orlando Church of Christ
             Florida Teen Camp
             210 N. Goldenrod Road, #4
             Orlando, FL 32807

Mark Your Calendar with these Important Dates.

       Counselor/Additional Staff Decision date – Tuesday, June 15th
       Counselor Orientation this year will be held at the camp on the Saturday before
          Teen Camp begins, August 6th, at 10:00 a.m.
       Teens arrive at camp on Sunday, August 8th
                                        2011 Florida Teen Camp
                           Camp Counselor/Additional Staff/Activities Coordinator Application
                                          Application Deadline: June 1, 2011
INSTRUCTIONS                                                BACKGROUND QUESTIONNAIRE
Mail your completed and signed application to:              Please answer all of the following questions.
          Orlando Church of Christ
          2011 Florida Teen Camp
                                                            1) Have you ever been disciplined for your work with
          210 North Goldenrod Road, #4
          Orlando, FL 32807                                 children? ________ If yes, explain: ___________________
Name: __________________________________________
                                                            2) Have you ever been convicted of or pleaded guilty to a
*Maiden Name: ___________________________________
                                                            crime: ________ If yes, explain: _____________________
Gender:       Male       Female
                                                            3) Have you ever abused or molested a child (if unclear, seek
Current Address: __________________________________
                                                            legal counsel)? ___________________________________
City, State, Zip: ___________________________________
                                                            4) Have you been approved to work in the Children’s
*Previous Address: ________________________________
                                                            Ministry program of your local congregation?        Yes       No
City, State, Zip: ___________________________________
                                                            If no, see your Children’s Ministry Leader to get approved.
Birth Date: ______________________________________
                                                            5) When did you last serve in the Children’s Ministry
Home Phone:          (    )_____________________________
                                                            program of your local congregation? __________________
Cell Phone:          (    )_____________________________
                                                            6) Is there any matter that may disqualify you from serving
Email: __________________________________________
                                                            as a camp counselor/add staff: ______________________
Baptism Date: __________ What Church: ______________
*Attach a copy of Drivers License or Identification Card
                                                            MINISTRY LEADER REFERENCE
*Social Security #: _________________________________
                                                            Ministry Leader, please review the above application and
Adult T-shirt size: S M L XL XXL             XXXL
                                                            write   a   recommendation        stating   your   approval   or
Name: __________________________________________            disapproval of this applicant volunteering to serve as a
Relationship: _____________________________________         counselor/add staff for Florida Teen Camp.
Phone:             (      ) ____________________________ _______________________________________________
Number of years worked as a counselor/add staff for Florida
Teen Camp: ______________________________________
Additional Experience Working with Youth: _____________
Special skills/qualifications (Nurse, Lifeguard, CPR Trained,
etc.): ___________________________________________
Do you have a Florida Driver’s License? Yes         No
Do you have car insurance?        Yes   No                  _______________________________     _____________________________
                                                            Print Ministry Leader’s Name        Signature of Ministry Leader
                                                             (Ministry Leader: Upon completion of reference, mail
On the back of this page, describe why you want to be a teen application to Orlando Church of Christ by June 1, 2011.)
camp counselor and what you can provide for the teens in
                                                             *Needed for background check.
order to help them get the most out of their experience.
                                        2011 Florida Teen Camp
                                  Camp Counselor/Additional Staff Application—page 2
                                            Name: __________________________
MEDICAL INFORMATION                                               RELEASE/SIGNATURE (READ CAREFULLY!)
Medications: Please list all medications – prescription and            Should it be necessary for me to receive medical
                                                                  attention/treatment while participating in the camp
non-prescription – taken routinely. Bring medication in the       activities, I hereby give my permission for the person(s)
original - package/bottle that identifies the name, prescribing   leading or directing these activities to render medical
                                                                  attention or administer medical treatment, as the
physician, name of drug, dosage and frequency.                    physician/medical professional deems appropriate and
                                                                  necessary. I, also, give my permission for the person(s)
Medication #1: __________________________________                 leading or directing these activities to use their best
                                                                  judgment to otherwise render assistance (i.e. First Air, CPR,
Dosage: ________________________________________                  etc.) in the event of injury or illness.
Time to be Taken: ________________________________                     I understand that the Orlando Church of Christ or
                                                                  any person(s) leading or directing these activities has
Reason for Taking: ________________________________
                                                                  no insurance coverage for medical or hospital cost for
Medication #2: _________________________________                  me, which are associated with injury or illness occurring in
                                                                  the course of these activities (unless the participant is already
Dosage: _________________________________________
                                                                  covered under the church’s employee health plan).
Time to be Taken: _________________________________               Therefore, any costs incurred for such medical
                                                                  attention/treatment shall be my sole responsibility.
Reason for Taking: ________________________________
                                                                       I further authorize any references or churches listed
List additional medications on back of this page.                 in this application to give the Orlando Church of Christ
Allergies: (medication, food, environmental):                     any information (including opinions) that they may have
                                                                  regarding my character and fitness for children or youth
________________________________________________                  work. In addition, I authorize the Orlando Church of
________________________________________________                  Christ to do a background check on me at their
                                                                  discretion. In consideration of the receipt and evaluation
________________________________________________                  of this application by the Orlando Church of Christ, I
________________________________________________                  hereby release any individual, church, youth organization,
                                                                  charity, employer, reference, or any other person or
Health History:                                                   organization, including record custodians, both collectively
Please identify any chronic or recurring illness/condition:       and incidentally, from any and all liability for damages of
                                                                  whatever kind or nature which may at any time result to me,
________________________________________________                  my heirs, or family, on account of compliance or any
________________________________________________                  attempts to comply with this authorization. I understand
                                                                  that upon my written request, I will be given a copy of the
________________________________________________                  background report and, when applicable, a written
________________________________________________                  description of my rights under the Fair Credit Report Act.
                                                                       Should my application be accepted, I agree to be
Do you have a condition that requires you to carry an             bound by the Bylaws and policies of the Orlando
epinephrine pen or inhaler?     Yes      No                       Church of Christ and to refrain from unscriptural
                                                                  conduct in the performance of my services on behalf of
Medical Insurance: (Please attach a copy of your health           the church. The information contained in this application
card to this form.)                                               is correct to the best of my knowledge. I further state that I
                                                                  HAVE CAREFULLY READ THE FOREGOING
Company: _______________________________________                  RELEASE AND KNOW THE CONTENTS THEREOF
Policy Number: __________________________________                 AND I SIGN THIS RELEASE OF MY OWN FREE
                                                                  ACT. This is a legally binding agreement which I have read
Group Number: __________________________________                  and understand.
Claims Address: __________________________________
Phone: (      )____________________________________               _______________________________________________________________________________________   _____________________________________

                                                                  Applicant’s signature                                                                     Date

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