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First
Name:
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| Last
Name : |
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| Age: |
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| Sex: |
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Address : |
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City: |
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State: |
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Zip: |
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Home
Phone:
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| Cell
Phone: |
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E-mail
Address:
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| Have
You Worked At Camp Before: |
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| If
Yes When: |
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| Previous
Positions: |
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| Are
You A Christian: |
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| Year
Saved: |
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| Home
Church Name: |
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| Pastor's
Name And Number: |
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| Have
You Ever Been Convicted Of Or Pleaded Guilty To A Crime?: |
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| Have
You Ever Been Investigated For Neglect Or Child Abuse?: |
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| Do
We Have Permission To Obtain A Background Check?: |
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| Do
You Have A Current Driver's License?: If Yes Provide A
Copy / If No Provide A Pic. ID. |
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| Please
List The Names & Contact #'s Of Two Non-Related Personal
References: |
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Choose
as many as interest you indicating your primary preference
as 1, 2, 3, etc.
(select from the list below - if you have no interest
in a particular area leave it blank):
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| Counselor: |
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| Kitchen: |
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| Snack
Shack: |
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| Maintenance: |
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| Recreation: |
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| Whatever
Needed: |
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| Other
(Please List): |
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Medical
Insurance Information
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| Do
You Have Insurance?: |
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| Insurance
Company Name: |
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| Policy
Number : |
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| Group
Number : |
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| Doctor's
Name: |
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| If
you are under 18 years of age please have your parents
sign this medical release: In the event my child needs
emergency medical attention, I hereby give my consent
for the officials of the camp to seek medical assistance.
I further understand that the camp will make every attempt
to notify me of such action as is possible. |
| Name
Of Child: |
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| Parent's
Signature: (Type your first and last name) |
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| Date:
(put today's date in the box) |
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Applicant's
Statement
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| The
information contained in the application is correct to
the best of my knowledge. I authorize any references or
churches listed in this application to give you any information
that they may have regarding my character and fitness
for youth camp work. In consideration of the receipt and
evaluation of this application by the leaders of Mt Moriah
Youth Camp, I hereby release to any individual, organization,
charity, employer, reference or any other person, including
record custodians, both collectively and individually,
from any and all liability for damages of whatever kind
or nature which may at this time result to me, my heirs,
or family, on account of compliance or any attempt to
comply with this person or organization identified by
me in this application. Should my application be accepted,
I agree to be bound by the laws and policies of Mt Moriah
and to refrain from any unscriptural conduct in the performance
of my services on behalf of the church. I also agree to
participate in the training and enhancement programs provided
by the leaders of Mt Moriah in preparation of my participation
this summer. 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. |
| Applicant's
Signature: (Type your first and last name) |
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| Today's
Date: (put today's date in the box) |
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| Pastor's
Signature: (Type in first and last name) |
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| Today's
Date: (put today's date in the box) |
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| Youth
Pastor's Signature: (Type in first and last name) |
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| Today's
Date: (put today's date in the box) |
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