Royal Family Counselor Application

For Office Use Only ______Received ______Interviewed ______Contacted ______Fingerprinted

 Training #1  Training #2  Training #3  Training #4

Roy al Fam ily Kids Cam p of South Dallas Royal Family Kids Camp Sponsored by Southwestern Assemblies of God University and Trinity Church Royal Family Kids Camps . 1200 Sycamore . Waxahachie, TX 75165 . 469-547-7352 www.southdallas.royalfamilykids.org . [email protected] June 28 - July 3 • 2015 C O U N S E L O R / S T A F F A P P L I C A T I O N

Instructions: Please Print. All information is held strictly confidential. This form must be completely filled out or will not be accepted. The information is vital to your acceptance and placement as a volunteer.

______Date Current Drivers License # Social Security # (a photocopy of license must accompany application) ______M or F______/_____/______Last Name First Name Sex Birthdate

______/______Street (address where you are living now or where you will be living this summer) Age Marital Status

______City State Zip

______Email address (check email often this is how we will contact you) Facebook ~ name you use on FB

______Occupation Name of Employer Number of years

How long have you lived in [state]? ______Years and ______months If you have lived in [state] for less than one year, list your complete addresses for the last five years:

of 7, 00134c67e5a922d6c4db2e3ba49a1f7d.docx, 5/07 (______)______Cell Phone (we need a good number we can contact you this summer)

______(______)______Emergency Contact Relationship Phone

T-Shirt Size:  Adult Small  Adult Medium  Adult Large  Adult X-Large  Adult XX-Large 3X

Do you have certification in the following?  CPR  First Aid  Life Guard  Nurse  EMT Do you have previous training or background in dealing with abused, neglected or abandoned children?  No  Yes. In what way:______(Use back of paper if needed)

Were you a victim of abuse, neglect or abandonment as a minor?  NO  YES,  Yes, but I would prefer to discuss this in person. Please Clarify: ______

______

Please describe why you wish to be a counselor for abused kids (use the back for space if necessary)

______

MEDICAL HISTORY Do you have any medical conditions?  NO  YES, if yes please describe:

______Do you take any medications?  NO  YES, please list medicine, reason and any side effects:

______

of 7, 00134c67e5a922d6c4db2e3ba49a1f7d.docx, 5/07 Have you had any serious illness or injuries in the last three years?  NO  Yes, please list:

Have you any physical handicaps or conditions preventing you from performing any type of activity?  NO  YES, please list

RECORD OF EDUCATION High School Name: ______Date of Graduation:______

College: ______Major:______Date of Graduation:______

Other: ______Major:______Date of Graduation:______

PERSONAL REFERENCES (not former employers or relatives)

1. ______Name Address Phone

Please be sure we will be able to reach your references and that their address and phone number are correct. You must have 3 references with their complete address and phone number or your application will not be accepted.

______For Office use only

Reference 1______

______

Reference 2______

______

of 7, 00134c67e5a922d6c4db2e3ba49a1f7d.docx, 5/07 Reference 3______

______

Other______

PERSONAL PROFILE Have you committed your life to Jesus Christ?  NO  YES Where & When:______What church do you presently attend? ______How long? ______Yrs. ______Mos. Pastor’s Name: ______Church Phone #:______Do you have any previous experience working with children?  NO  YES, please describe:

______

Do you have any previous experience working with abused children?  NO  YES, please describe:

______

Do you feel you could lead 15-minute devotion with your campers with material we provide?  YES  NO

Please circle all the words below which you believe accurately describe you: Timid Gentle Impatient Modest Nervous Loving

Tactful Mature Sarcastic Patient Angry Deliberate

Congenial Compassionate Stubborn Kind Studious Selfish

Secure Considerate Abrasive Trustworthy Motivated Verbal

Organized Impulsive Intelligent Insecure Relaxed

List below, five strengths and five weaknesses you have in working with children (please be specific) Strengths

of 7, 00134c67e5a922d6c4db2e3ba49a1f7d.docx, 5/07 1.______2.______3.______4.______5.______Weaknesses 1.______2.______3.______4.______5.______

I would prefer my campers to be:  7 Yrs Old  8 Yrs Old  9 Yrs Old  10 Yrs Old  11 Yrs Old

of 7, 00134c67e5a922d6c4db2e3ba49a1f7d.docx, 5/07 Have you ever been arrested for a criminal offense?  NO  YES Have you ever been convicted of or plead guilty to a crime?  NO  YES Have you ever been arrested for sexual misconduct?  NO  YES Have you ever been convicted of or plead guilty to sexual misconduct?  NO  YES Have you ever taken drugs other than prescription drugs?  NO  YES Do you currently: use tobacco  NO  YES use alcohol  NO  YES use drugs  NO  YES If you answered “YES” to any of the above please explain on the reverse side of this form.

Applicant’s Statement 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 and fitness for children or youth work. In consideration of the receipt and evaluation of this application by Trinity Church, I hereby release any individual, church, youth organization, charity, employer reference, or any other person or organization, including record custodians, both collectively and individually from any and all liability for 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 that I may have to inspect any information provided about me by any person or organization identified by me in this application.

I further state that 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.

Please be advised that a criminal history check will be requested from the state(s) of Texas and that listed in your address (as authorized by state law).

If I am accepted as a counselor or staff member, I will: 1. Attend ALL hours of training; (New volunteers must complete 12 hours; Returning volunteers, 8 hours) 2. Participate in the entire week of camp (see schedule below)

TRAINING: Saturday, April 11 (breakfast and lunch provided) New volunteers: 8:00am-5:00pm Returning volunteers: 12:00pm – 5:00pm BASIC CAMP SCHEDULE: Begin on Sunday, June 28, 8:30am; End on Friday, July 3, 7:30pm Basic Sunday Schedule (June 28): Arrive at Trinity Church at 8:30am. We will all attend the 9:00am service in order to be “commissioned” in front of the church. We will then attend only the first half of the 11:00am service for commissioning. After departing from the second service, we will leave Trinity Church and make our way to McCafferty Hall at SAGU, where we will have lunch at 12:30pm and the remaining of our training from 1:00-4:00pm. We then set up the camp Basic Friday Schedule (July 3): After arriving back at Trinity Church with the campers, we will say “Good-bye” and then share in a dinner, the “Welcome Home” dinner (which will end at 7:30pm)

______Print Name Signature Date

______Witness Name Witness Signature Date Please submit your completed form by February 13th through one of these methods:

of 7, 00134c67e5a922d6c4db2e3ba49a1f7d.docx, 5/07 1. Mail to the address listed at the top of the first page; 2. Deliver to the office of the camp director, Darren Daugherty, Scheaffer Building #2241, SAGU; 3. Deliver to the office of the assistant camp director, Matt McKay, Children’s Center, Trinity Church.

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