VOLUNTEER STAFF APPLICATION FORM

Adult Special Needs Fall Retreat

PERSONAL INFORMATION

Name:

Last

First

Middle

Preferred Name

Sex

Age

Date of Birth

Social Security Number

Height

Weight

Driver ˇs License Number

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)

___________________________________________

fi Freshman

fi Sophomore

fi Junior

fi 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?

fi Yes

fi No

Pastor ˇs Name

Church Telephone (

)

List responsibilities/activities in your home church. _________________________

___________________________________________________________________

INDICATE EXPERIENCE IN THE FOLLOWING:

None

Some

Extensive

None

Some

Extensive

None

Some

Extensive

Recreation

fi

fi

fi

Drama

fi

fi

fi

Camp Staffer

fi

fi

fi

Puppets

fi

fi

fi

Lifeguard

fi

fi

fi

Clowning

fi

fi

fi

Bible Teaching

fi

fi

fi

Special Needs

fi

fi

fi

Juggling

fi

fi

fi

Lead Fellowship

fi

fi

fi

VBS/Day Camps

fi

fi

fi

Song Leading

fi

fi

fi

Lead Devotion

fi

fi

fi

Singing

fi

fi

fi

Working with

fi

fi

fi

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)

fi

Piano ____________________________

fi

Guitar ____________________________

fi

Other ____________________________

---

LANGUAGE/PROFICIENCY LEVEL (including American Sign Language) Read

Write

Speak Some

Fluent

1. _____________________________

fl

fl

fl

fl

2. _____________________________

fl

fl

fl

fl

3. _____________________________

fl

fl

fl

fl

HEALTH INFORMATION

My health is

fi

Excellent

fi

Fair

fi

Poor

Are you allergic to any medications?

fl

Yes

fl

No

If so, what? ___________________

Are you currently under any

medication?

fi

Yes

fi

No

If so, what?

_______________________

Are you under a physician ˇs care due to physical

conditions which may limit your ability to serve in

some assignments (i.e., serious allergies requiring

medication, vision problems, back problems, etc.)?

fi

Yes

fi

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?

fi

Yes

fi

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 ˇs Signature

Date

___________________________________________________

_________________________________

Parent/Guardian Signature

(If applicant is a minor)

Date

Return completed application to Debra Stanley, Office 3800 North May Avenue, Oklahoma City, OK 73112