Name *

First Name

Last Name

Have you committed your life to Jesus Christ? *

No

Yes

Do you currently attend church?

No

Yes

Do you have any previous experience working with children? *

No

Yes

Do you have any previous experience working with abused children? *

No

Yes

Do you feel you could lead a 15 minute devotion with your campers, if we provide the materials? *

No

Yes

Please check all that you believe accurately describe you *

Compassionate

Congenial

Talkative

Nervous

Gentle

Angry

Enthusiastic

Impatient

Abrasive

Passive

Loving

Quiet

Considerate

Impulsive

Friendly

Patient

Mature

Timid

Trustworthy

Organized

Stubborn

Selfish

Secure

Loud

Intelligent

Motivated

Insecure

Relaxed

Modest

Kind

Deliberate

Studious

Sarcastic

Tactful

Verbal

Shy

Have you ever been arrested, plead guilty, or convicted for a criminal offense? *

No

Yes

Have you ever received deferred adjudication or similar disposition for any federal, state, or municipal criminal offense? *

No

Yes

Have you ever been arrested, plead guilty, or convicted for sexual misconduct? *

No

Yes

Have you ever received probation or community supervision for any federal, state, or municipal criminal offense? *

No

Yes

Have you ever been convicted of any criminal offense in a country outside the jurisdiction of the United States? *

No

Yes

As of the date of this application, do you have any pending criminal charges against you? *

No

Yes

Have you ever used illegal drugs or misused prescription drugs? *

No

Yes

Reference #1 *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Reference #2

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Reference #2

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Graduation

MM

DD

YYYY

Date of Graduation

MM

DD

YYYY

Do you have any medical conditions? *

No

Yes

Do you take any medications? *

No

Yes

Have you had any serious illness or injuries in the last three(3) years? *

No

Yes

Do you have physical handicaps or conditions preventing you from performing any type of activity? *

No

Yes

Do you currently use tobacco? *

No

Yes

Do you currently drink alcohol on a regular basis? *

No

Yes

Are you currently serving or have you served in the United States military? *

No

Yes

If you are no longer serving in the military, did you receive a DD214?

Skip if you've never been in the military

No

Yes

If you served, did you receive an honorable discharge?

Skip if you've never been in the military or if still active

No

Yes

T-Shirt Size *

XS

S

M

L

XL

2X

3X

Other

Are you applying for a Big Camper or Big Camper In Training position? *

No

Yes

Do you have certification in any of the following?

First Aid

CPR

Nurse

EMT

Life Guard

Do you have previous training or background in dealing with abused, neglected, or abandoned children? *

No

Yes

Were you a victim of abuse, neglect, or abandonment as a minor? *

No

Yes

Do you agree with the following applicant statement? *

The information contained in this application is correct to the best of my knowledge. I authorize any references or churches listed in this application to give you any information (including opinions) that they may have regarding my character and fitness for children or youth work. In consideration of the receipt and evaluation of this application by Palmerdale United Methodist Church and Royal Family KIDS Camp #218, I hereby release any individual, church, youth organization, charity, employer reference, or any other person or organization, including record custodians, both collectively and individually, 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 waive any right that I may have to inspect any information provided about me by any person or organization identified by me in this application. I further state that I have carefully read the foregoing release and know the contents thereof and I sign this release as my own free act. This is a legally binding agreement which I have read and understand. Please be advised that a criminal history check will be requested from the state of Alabama as authorized by state law.

No

Yes

Do you agree to the following disclosure statement(s)? *

In connection with your application for employment or volunteer service with: Royal Family Kids, Camp #218 and Palmerdale United Methodist Church (including any independent contract for services) or when deciding whether to modify or continue your ongoing employment (if hired) or service, Royal Family Kids, Camp #218 and Palmerdale United Methodist Church may obtain a “consumer report” and/or an “investigative consumer report” on you from Verified Volunteers, a consumer reporting agency, or from any third party, in strict compliance with both state and federal law. A consumer report is a communication of information by a consumer reporting agency bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used for purposes of serving as a factor in establishing your current and/or continuing eligibility for employment purposes. An investigative consumer report is a report obtained through personal interviews with individuals who may have knowledge of your character, general reputation, personal characteristics, or mode of living. The consumer reports or investigative consumer reports may contain information regarding your credit history (if applicable to position), criminal records, driving history records, education records, previous employment history, social security traces, military records, professional licensure records, drug testing, government records, and other types of background information. You further understand that these reports may contain information concerning the reasons for termination of past employment. You are hereby notified that you have the right to make a timely request for the nature and scope of any investigative consumer report. You are further notified that, prior to being denied employment/volunteer status based in whole or in part on information obtained in the consumer report, you will be provided a copy of the report, and the name, the address and telephone number of the consumer reporting agency.

No

Yes

Date Of Birth *

MM

DD

YYYY

Do you have a valid driver's license? *

No

Yes

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date you moved to your current address *

MM

DD

YYYY

Information Certification

By indicating below, I certify: (1) that I have read and fully understand this disclosure and authorization; (2) that all of the information I am providing is true, complete, correct and accurate; and (3) that I have received the attached Summary of Your Rights under the Fair Credit Reporting Act (15 U.S.C. §1681 et seq.).

I disagree

I agree