Name *
Name
Address *
Address
Home Phone
Home Phone
Mobile Phone
Mobile Phone
Date of Birth *
Date of Birth
This information can also be given by calling the camp office (717) 545-2841
Parent's Name(s) *
Parent's Name(s)
Church Address
Church Address
Church Phone
Church Phone
Pastor
Pastor
At Mt. Lou San, the ministry depends on qualified and capable staff members and willing and faithful volunteers. We appreciate your willingness to partner with us in the purpose of connecting people to the truths of God’s Word for life-change. The state of Pennsylvania requires a background check on anyone working in close proximity with children. Once you have completed the application and we have made the necessary background checks, we will inform you of your status.
Check the position(s) which you would desire to fill *
Briefly share how you came to know Christ as Savior
Why do you desire to work at Mt. Lou San?
What do you think about your child working at Mt. Lou San this summer?
Please list: Organization - Program - Dates - Contact
What church or churches have you attended in the past five years? Please list: Church name - Pastor's name - Years attended
Please list: Name/Relationship - Email Address - Phone
Children’s/Youth Work Verification and Release
I recognize that Mt. Lou San is relying on the accuracy of the information I provide on the Staff/Volunteer Application form. Accordingly, I attest and affirm that the information I have provided is absolutely true and correct.

I authorize the organization to contact any person or entity listed on the Staff/Volunteer Application form, and I further authorize any such person or entity to provide the organization with information, opinions and impressions relating to my background or qualifications.

I voluntarily release the organization and any such person or entity listed on the Staff/Volunteer Application form from liability involving the communication of information relating to my background or qualifications.

I further authorize the organization to conduct a criminal background check investigation if such a check is deemed necessary.

I have carefully read the policy and procedures of the organization, and I agree to abide by them and to protect the health and safety of the children or youth assigned to my care or supervision at all times.
I agree that this electronic signature is the legal equivalent of my manual signature.
Date *
Date
Medical History
Doctor's Phone
Doctor's Phone
Date of last Tetanus shot *
Date of last Tetanus shot
Medical Treatment Release: I hereby give permission to the camp nurse and/or the physician selected by the camp director and/or camp nurse to administer routine treatment/medication; and in case of medical and/or surgical emergency to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child.
I agree that this electronic signature is the legal equivalent of my manual signature.
Date *
Date
Please click on the link above and read the statement of faith. Then, if in agreement, come back to this page and sign below
I agree that this electronic signature is the legal equivalent of my manual signature.
Date *
Date