Camp Luther, WV: for Staff Members

for Staff Members

(Must be submitted by April 1, 2010)

Your Information
First Name:
Last Name:
Street Address:
City:
State:
Zip Code:
E-mail Address
Home Phone:
Mobile Phone:
Birth Date:
T-Shirt Size (for new staffmembers only):	XS S M L XL XXL XXXL

Your Home Church
Church Name:
Address:
City:
State:
Zip Code:
Phone Number:
Pastor's Name:
In what way are you involved in the worship and/or ministry of your church?
Are you involved in any other church related or religious activities?
Will your pastor verify this information?	Yes No Not Sure

General Information
In which capacity would you like to serve? (Check all that apply)	Dean Counselor Chaplain Nurse Office Staff Spiritual Director Webpage Photographer Psychologist Director

Are you qualified to teach any of these subjects? (Check all that apply)	Bible Catechism Camp Curriculum Music Nature Crafts Sports Newspaper Swimming Creative Arts

In which program would you like to serve? (Check all that apply)	Junior Program ( Grades 3 – 5 ) Intermediate Program ( Grades 6 – 8 ) Senior Program ( Grades 9 – 12 )
Do you have certification in either of the following? (Check all that apply) Please be prepared to present your certificate upon request.	Life Saving First Aid
Have you taken the training for "Safeguarding God's Children"?	Yes No
If so, where and when?
What else would you like to tell us?
Do you plan to attend Work Day (April 24, 2010) to help finalize camp plans for the week, and spruce up camp?	Yes No Unsure at this time

Background Information
Personal References – Note: new staffmembers are required to provide letters of reference from the three individuals you list below.
Personal Reference 1
Name:
Address:
Phone Number:
Personal Reference 2
Name:
Address:
Phone:
Personal Reference 3
Name:
Address:
Phone:

Have you ever been discharged or forced to resign from employment or a volunteer role?	Yes No
If yes, please give the details, including the name of the employer or group.

Have you ever been convicted of a crime, or are you under charges for any offense against the law, other than minor traffic violations?	Yes No
If yes, please give the details, including the county in which the offense took place.

Health Statement
Do you wear:	Eyeglasses? Contacts?
Have you had any serious illnesses within the past year? If so, please explain.
Do you have any allergies?	Yes No
If yes, please explain and describe any medications needed:
Do you have any drug allergies?	Yes No
If yes, please explain:
Do you have any of the listed medical conditions?	Diabetes Heart Condition Epilepsy / Convulsions Emotional Problems Ear Problems Asthma Fainting Spells Hay Fever
If you checked any of the above conditions, please describe any treatments or medications used.
Date of your most recent tetanus immunization?
Do you have any other condition (physical or emotional) of which the Nursing Staff should be aware?
Are you taking any medications other than those described above?

Emergency Contact Information
Doctor's Name:
Doctor's Phone:
Address:
City, State, Zip

Name of person to contact in case of an emergency:
Emergency contact phone number:
Emergency contact alternate phone number:
Certification (Please read this statement carefully before signing) I hereby certify that my answers to the above questions/statements are true, complete, and correct. I understand that false answers on this application may be grounds for immediate dismissal from Camp Luther. I also understand that the above answers are subject to verification.
By typing your full legal name here, you are signing this document electronically with the same legal power as a written signature.	Full Name: Date Signed: