Counselors Screening

This application is to be completed by all applicants for any position (volunteer or compensated) involving the supervision or custody of minors. This is not an employment application form. This form is being used to help Central California Youth Camp provide a safe and secure environment for those children and youth who participate in our programs and use our facilities.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email(Required)

Phone(Required)

Have you ever been convicted of or pleaded guilty to a felony?(Required)

Yes

Please explain.(Required)

Were you a victim of abuse or molestation while a minor?(Required)

Yes

If you prefer, you may refuse to answer this question, or you may discuss your answer in confidence with the camp director rather than answering it on this form. Answering yes, or leaving the question unanswered, will not automatically disqualify an applicant for children or youth work.

PERSONAL REFERENCES

(not former employers or relatives)

References

Church History

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 for children or youth work. In consideration of this receipt and evaluation of this organization, charity, employer, reference, or any other person or organization, including record custodians, both collectively and individually, form any and all 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 I may have to inspect any information provided about me by any person or organization identified by me in this application. Should I be asked to fill a position, pursuant to this application, I agree to be bound by the by-laws, articles of faith and policies of Central California Youth Camp, and to refrain from unscriptural conduct in the performance of my services on behalf of Central California Youth Camp. 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.

Do you have your Pastor's permission?(Required)

Yes

Signature(Required)