Michigan Summer Outbreak 2015
Counselor & Staff Application
Church of God Camp Grounds ♦ 6317 Old US 23 ♦ Fenton, MI 48430
(810) 629-0460 ♦ Fax (810) 629-0693 ♦ www.michigancog.org
To work at camp, one must be a committed Christian and in good standing in a local Church of God congregation. Older
Teen Camp workers must be at least 20, and Young Teen Camp workers must be at least 18. In younger camps, a limited
number of teenagers ages 15-17 may be accepted as a Counselor-In-Training or a Worker-In-Training provided they are
needed. Priority will be given to adult workers. Persons age 14 or younger need not apply.
Also, to work at camp you will need to complete the following:
 Counselor & Staff Application
 Application must be signed by your Pastor
 Central Registry/Background Check filled out– If you filled one out last year you do not need to do a new one.
 Must return application by June 5, 2015
Please Print All Information
Name:______________________________________________________
(Last Name)
__Male
__Female
__ingle
__ Married
(First)
Address:_________________________________________________________________________________________
(Number & Street)
(City)
(State)
(Zip)
How long have you lived at the address: _____ If less than 2 years give previous Address: _______________________
E-mail: __________________________________________________ Phone: (_____) ________ - ____________
Age: _____
Birthdate:___/___/____
T-Shirt Size: S M L XL XXL XXXL XXXXL
Emergency Contact Name: ____________________________________________ Phone: ( ____) ______-__________
Check Which Camp You Would Like To Work
Sr. High Camp (Age 14-19) June 22-26
Jr. High Camp (Age 11-13) June 29-July
Kids Camp (Age 7-10) July 6-10
Position You Desire To Work
Counselor:
A counselor is assigned to care for a group of campers (10-12). Special qualities include: leadership and
communication skills, a sense of humor, patience and a deep Christian commitment to love young people.
1. Will your child be a camper the same week? Yes/No Do you want your child placed in your room? Yes/No
2. Will campers from your church be in your camp? Yes/No Should they be placed in your room? Yes/No
Staff:
In addition to working in a specific area, such as recreation or canteen, staff members are called upon to help
where ever a need arises. Staff must be flexible and maintain a positive second mile attitude.
Assistant Counselor
Audio/Visual Team
Recreation Staff
Video Team
Life Guard (Must Be Certified)
Canteen Staff
Kitchen Staff
Camp Store Staff
Night Watchman
Nurse (Must Be Certified)
Educational Background (Enter highest year completed in appropriate space)
Middle School (Grades 6-8) _____ High School (Grades 9-12) _____ College (1-4) _____ Graduate School _____
Spiritual Status
Saved
Sanctified
Holy Spirit Baptism
Baptized in Water
Church Member
Other Information
Do you have any health problems or physical limitations? Yes/No If yes, please explain: ______________________________________
_____________________________________________________________________________________________________________
Allergies: __________________________________________________________________ Date of last tetanus shot: ______________
Current Medications: ____________________________________________________________________________________________
_____________________________________________________________________________________________________________
In case of an accident or a serious illness you have my permission to secure the proper medical treatment.
(If under 18, parental signature required)
Signature: ___________________________________________________________________________ Date: ____________________
Name of church you attend: ____________________________________________________Pastor: ____________________________
Local Church Involvement: _______________________________________________________________________________________
_____________________________________________________________________________________________________________
Insurance Coverage
Insurance Company _____________________________________________ Policy # ____________________ Group # ____________
Address __________________________________City _____________ State ____ Zip ______ Phone # __________________________
Background Information
The following questions are placed here at the advice of our legal counsel. All questions must be answered. All responses are kept in
strict confidence.
1.
2.
3.
4.
5.
Have you ever been arrested, convicted or pled guilty to any
crime?
Yes/ No
If yes, would you be willing to discuss this matter with a
pastor or ministry leader?
Yes/ No
Have you ever been accused, charged or alleged to have
committed any act of neglecting, abusing or molesting a child
or youth?
Yes/ No
If yes, would you be willing to discuss this matter with a
pastor or ministry leader?
Yes/ No
Have you ever been a victim of abuse (verbal, physical,
sexual)?
Yes/ No
If you prefer, you may discuss the answer to the
pervious question with a pastor or ministry leader.
Answering “Yes” or leaving it unanswered would not
automatically disqualify you from the privilege of working
in any ministry capacity. However you may be asked to
clarify your response.
Have you ever been involved in homosexual activity?
Yes/ No
If yes, would you be willing to discuss this matter with a
pastor or ministry leader?
Yes/ No
Have you ever been accused , charged or alleged to have
committed theft?
Yes/ No
6.
Are you addicted to prescription drugs?
Yes/ No
7.
Do you use tobacco in any form?
Yes/ No
8.
Do you drink alcoholic beverages?
Yes/ No
9.
Do you take illegal drugs?
Yes/ No
10. Do you have problems sleeping?
Yes/ No
11. Do you have recurring nightmares or sleep disturbances?
Yes/ No
12. Do you have a history of use of pornographic materials?
Yes/ No
13. Have you ever been charged with moving traffic violations?
Yes/ No
14. Has your driver’s license ever been revoked or suspended?
Yes/ No
Applicant’s Signature: __________________________________
Date: ______________________
Applicant Statement
The information contained in this application is correct to the best of my knowledge. I authorize any references issued in this application
to give you any information (including opinions) that they may have regarding my character or fitness for children or youth work. In consideration of the receipt and evaluation of this application by the Church of God, 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 damage or whatever kind of 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. Should my application be accepted, I agree to be bound by the bylaws and polices
of the Church of God, and to refrain from unscriptural conduct in the performance of my services on behalf of the church. I further state
that I have carefully read the foregoing release and know the contents. This is a legally binding agreement which I have read and understand.
Applicant’s Signature __________________________________ Date ______
Witness Signature _____________________________________ Date ______
Character Endorsement
Senior Pastor’s Signature REQUIRED
I certify that the applicant is a capable and qualified person to work in Church of God youth camp and
I give them my highest recommendation to serve in any capacity deemed necessary by the State
Director of Youth and Christian Education.
Pastor (Print Name) ____________________________________________________________
Phone (_____) ___________________ How long have you known this person? _____________
Pastor’s Signature Required Here __________________________________________________
Date _________________
Criminal Records Check Authorization
I hereby authorize Michigan Church of God and its designated agents to conduct a
comprehensive review of my background. I understand that the scope of this report
may include, but not limited to the following areas: civil and history records from any
criminal justice agency in any or all federal, state, county jurisdictions and any other
public records. I further authorize any individual, company, firm, corporation, or public
agency to divulge any and all information, verbal or written, pertaining to me to Michigan
Church of God or its agents. I hereby release Michigan Church of God and designated
agents from any and all liability resulting from such disclosure.
Signature _________________________________________________
SS#________________________________________________________
Print Name _______________________________________________
Statement Of Reservation
While no one is rejected to work or attend Church of God Youth Camp on the basis of race, color or creed, the State
Director of Youth and Christian Education does reserve the right to accept or reject an application for volunteer work
at Church of God Youth Camps after review of said application reveals that the services of the applicant would or
would not be in the best interest and success of the camp. Also, an application may be rejected due to the fact that
all positions have been filled for selected camp.
6317 Old US 23 / Fenton, MI 48430
Phone: 810.629.0460 / Fax: 810.629.0693
Email: [email protected]
Website: www.michigancog.org