VOLUNTEER STAFF APPLICATION FORM
    ____SpecialNeedsSummer
    Children’s
    Camp, CrossTimbers
    ___Adult Special Needs Fall Retreat
    (Please indicate event for which you are volunteering.)
    PERSONAL INFORMATION
    Name: Last
    First
    Middle
    Preferred Name
    Sex
    Age
    Date of Birth
    SocialSecurityNumber
    Height
    Weight
    Driver’sLi
    c
    e
    nseNumber
    U.S. Citizen
    Mailing Address:
    Street
    City
    State
    Zip
    E-Mail Address
    Day Telephone Number
    (
    )
    Evening or Cell Phone Number
    (
    )
    Name of Parents/Guardian or Emergency Contact:
    Phone number for Parents/Guardian or Emergency Contact:
    EDUCATION
    Name of school or college attending (Please do not put initials)
    ___________________________________________
    ?
    Freshman
    ?
    Sophomore
    ?
    Junior
    ?
    Senior
    List organizations and honors._____________________________________________________________________________
    _______________________________________________________________________________________________________________________
    Have you ever been charged with a crime, including a traffic violation? _____No ______Yes If yes, explain______________________________
    Have you ever been abused or molested or been accused of abusing or molesting a child or minor? _____No _____Yes
    Were you ever abused or molested as a child or minor? ____No ____Yes
    Do you give permission for us to obtain a background check? ____No ___Yes
    CHURCH INFORMATION
    Present Church Membership
    City
    State
    How Long a member?
    Do you attend church on
    a regular basis?
    ?
    Yes
    ?
    No
    Pastor’sNa
    me
    Church Telephone (
    )
    List responsibilities/activities in your home church. _________________________
    ___________________________________________________________________
    INDICATE EXPERIENCE IN THE FOLLOWING:
    None Some
    Extensive
    None
    Some
    Extensive
    None
    Some
    Extensive
    Recreation
    ?
    ?
    ?
    Drama
    ?
    ?
    ?
    Camp Staffer
    ?
    ?
    ?
    Puppets
    ?
    ?
    ?
    Lifeguard
    ?
    ?
    ?
    Clowning
    ?
    ?
    ?
    Bible Teaching
    ?
    ?
    ?
    Special Needs
    ?
    ?
    ?
    Juggling
    ?
    ?
    ?
    Lead Fellowship
    ?
    ?
    ?
    VBS/Day Camps
    ?
    ?
    ?
    Song Leading
    ?
    ?
    ?
    Lead Devotion
    ?
    ?
    ?
    Singing
    ?
    ?
    ?
    Working with
    ?
    ?
    ?
    Hearing Impaired
    Other experience you feel is helpful; please describe_____________________________________________________________________________
    Please include a recent photo we can send to before camp to the special needs child you will be paired with.
    INSTRUMENT/S PLAYED (Indicate skill level: Beginner, Intermediate, Advanced)
    ?
    Piano ____________________________
    ?
    Guitar ____________________________
    ?
    Other ____________________________
    LANGUAGE/PROFICIENCY LEVEL (including American Sign Language) Read
    Write
    Speak Some
    Fluent
    1. _____________________________
    ?
    ?
    ?
    ?
    2. _____________________________
    ?
    ?
    ?
    ?
    3. _____________________________
    ?
    ?
    ?
    ?
    HEALTH INFORMATION
    My health is
    ?
    Excellent
    ?
    Fair
    ?
    Poor
    Are you allergic to any medications?
    ?
    Yes
    ?
    No
    If so, what? ___________________
    Are you currently under any
    medication?
    ?
    Yes
    ?
    No
    If so, what?
    _______________________
    Areyo
    uunderaphysician’sc
    a
    r
    eduet
    ophysical
    conditions which may limit your ability to serve in
    some assignments (i.e., serious allergies requiring
    medication, vision problems, back problems, etc.)?
    ?
    Yes
    ?
    No If yes, please explain
    ______________________________________________
    If you now have or have ever had problems with any of the following, please indicate and explain.
    ____ Asthma
    ____Migraine Headaches
    ____Heart
    ____High Altitude Sickness
    ____ Diabetes
    ____Mononucleosis
    ____Nervous Disorder
    ____Psychiatric Counsel
    ____Tuberculosis
    ____Seizures
    ____Allergies
    ____Stomach
    Have you ever been or currently under psychiatric care?
    ?
    Yes
    ?
    No If yes, please explain.
    ______________________________________________________________________________________________________
    REFERENCES (GIVE THE NAME AND ADDRESS OF FOUR REFERENCES BELOW.)
    Reference
    Name
    Address, City, State, Zip
    Phone, including
    area code
    Pastor
    Sunday School Teacher
    Student/Youth Minister
    Adult Friend
    Please state your reason(s) for volunteering and briefly share your personal testimony, using a separate sheet if necessary:
    I understand that I will be under the guidelines and policies of the camp or retreat director and the Baptist General Convention of Oklahoma.
    ________________________________________________________
    _____________________________________
    Applicant’sSi
    gnature
    Date
    ___________________________________________________
    _________________________________
    Parent/Guardian Signature
    (If applicant is a minor)
    Date
    Return completed application to CrossTimbers Program Office 3800 North May Avenue Oklahoma City, OK 73112

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