Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Number

(###)

###

####

Age

Date of Birth

YYYY

Gender

Guardian / Parent Name(s)

First Name

Last Name

First Name

Last Name

Contact Number

(###)

###

####

Home Church

Church Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Church Phone

(###)

###

####

Pastor

First Name

Last Name

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) you are interested in:

Operational Staff (Op Staff)

First Aid Officer (possibly registered nurse)

Multimedia (Video/Photo)

Lifeguard

Administrative Assistant

Operational Staff Boys Leader

Operational Staff Girls Leader

Cabin Leader (Counselor)

Other thoughts about what type of work you are interested at Summer Camp?

What are some areas you would say you are skilled in that may relate to working at Summer Camp?

Salvation Testimony

Briefly share how you came to know Christ as Savior.

Ministry Testimony

Why do you desire to work at Mt. Lou San?

What other ministry experience do you have?

Do you now use, or have you ever used, narcotics, hallucinogens, or drugs not prescribed by a physician?

If yes, what kind and when?

Do you now drink alcoholic beverages?

Do you now use tobacco?

Have you at any time ever been arrested?

Have you at any time ever been convicted of, or pleaded guilty or no contest to, any crime?

Have you at any time ever engaged in, or been accused of, any child molestation, exploitation or abuse?

Are you aware of having any traits or tendencies that could pose a threat to children, youth or others?

Are you aware of any reason why you should not work with children, youth or others?

If the answer to any of these questions is “yes,” please explain in detail

Are you willing to give up any social habit that would lessen your effectiveness and your influence as a Mt. Lou San staff member?

Are you willing to abide by the rules and regulations set forth by the camp leadership to insure an effective investment of your time?

Are you willing to serve as a missionary and be responsible to raise personal support?

Church Activity

What church or churches have you attended in the past five years? Please list: Church name - Pastor's name - Years attended

References (Other than relatives). Please provide at least two.

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.

Digital Signature

I agree that this electronic signature is the legal equivalent of my manual signature.

Date

YYYY

Statement of Faith

Please click on "Statement of Faith" above and read the statement of faith. Then, if in agreement, come back to this page and sign below

I read and agree with the Statement of Faith

Yes

Policies and Procedures

Please click on "Policies and Procedures" above and read the policies and procedures. Then, if in agreement, come back to this page and sign below

I read and agree with the Policies and Procedures

Yes

Signature of Applicant

I agree that this electronic signature is the legal equivalent of my manual signature.

Date

YYYY

Staff Application

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