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Your Information
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| First Name: |
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| Last Name: |
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| Street Address: |
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| City: |
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| State: |
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| Zip Code: |
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| E-mail Address |
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| Home Phone: |
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| Mobile Phone: |
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| Birth Date: |
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| T-Shirt Size (for new staffmembers only): |
XS
S
M
L
XL
XXL
XXXL
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| Your Home Church |
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| Church Name: |
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| Address: |
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| City: |
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| State: |
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| Zip Code: |
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| Phone Number: |
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| Pastor's Name: |
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| In what way are you involved in the worship and/or ministry of your church? |
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| Are you involved in any other church related or religious activities? |
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| Will your pastor verify this information? |
Yes
No
Not Sure
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| General Information |
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| In which capacity would you like to serve? (Check all that apply) |
Dean
Counselor
Chaplain
Nurse
Office Staff
Spiritual Director
Webpage Photographer
Psychologist
Director
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| 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
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| 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 )
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Do you have certification in either of the following? (Check all that apply) Please be prepared to present your certificate upon request.
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Life Saving
First Aid
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| Have you taken the training for "Safeguarding God's Children"? |
Yes
No
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| If so, where and when? |
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| What else would you like to tell us? |
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| 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
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| Background Information |
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| Personal References – Note: new staffmembers are required to provide letters of reference from the three individuals you list below. |
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| Personal Reference 1 |
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| Name: |
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| Address: |
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| Phone Number: |
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| Personal Reference 2 |
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| Name: |
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| Address: |
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| Phone: |
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| Personal Reference 3 |
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| Name: |
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| Address: |
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| Phone: |
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| Have you ever been discharged or forced to resign from employment or a volunteer role? |
Yes
No
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| If yes, please give the details, including the name of the employer or group. |
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| 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
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| If yes, please give the details, including the county in which the offense took place. |
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| Health Statement |
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| Do you wear: |
Eyeglasses?
Contacts?
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| Have you had any serious illnesses within the past year? If so, please explain. |
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| Do you have any allergies? |
Yes
No
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| If yes, please explain and describe any medications needed: |
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| Do you have any drug allergies? |
Yes
No
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| If yes, please explain: |
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Do you have any of the listed medical conditions?
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Diabetes
Heart Condition
Epilepsy / Convulsions
Emotional Problems
Ear Problems
Asthma
Fainting Spells
Hay Fever
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| If you checked any of the above conditions, please describe any treatments or medications used. |
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| Date of your most recent tetanus immunization? |
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| Do you have any other condition (physical or emotional) of which the Nursing Staff should be aware? |
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| Are you taking any medications other than those described above? |
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| Emergency Contact Information |
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| Doctor's Name: |
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| Doctor's Phone: |
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| Address: |
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| City, State, Zip |
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| Name of person to contact in case of an emergency: |
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| Emergency contact phone number: |
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| Emergency contact alternate phone number: |
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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.
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By typing your full legal name here, you are signing this document electronically with the same legal power as a written signature.
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Full Name:
Date Signed:
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