Home

Volunteer Application Form for Camp Talahi

 

Volunteer Application 2008

Personal Information – Please print or type

Full Name ______________________________________________________

Position Desired: CIT   Counselor    Chaplain 

Session(s) Desired______________________________________________________                                              

 

Complete Address ____________________________________________________

______________________________________________________________________

Birthdate____________________Drivers License Number______________
 

Telephone Numbers

(w)__________________________

(h)__________________________

(c)__________________________

e-mail____________________________

 
Church Name and City_________________________________________________
Pastor’s Name__________________________Phone________________________
 
Education
School Name____________________________________Grade(in fall)__________
 
School Address_______________________________________________________
                                    Street                                       City                  State                ZIP
Work Experience
Employer_________________________________________________________
Address____________________________________________________________
                        Street                                                   City                  State                 ZIP
Dates Employed___________to__________________ Job Title________________
References
Give complete name, address, and telephone number of three references (not previous employer as listed above).
1.____________________________________________________________________
 
2.____________________________________________________________________
 
3.____________________________________________________________________
Signature

I certify that answers given in this application are true and complete to the best of my knowledge. I authorize all persons and all other entities to respond to inquiries from the Michigan Conference United Church of Christ, concerning me. I understand that such persons may comment on and state their opinions regarding my background and character to those considering me for employment in the Michigan Conference UCC.I encourage such persons to speak openly and responsibly, and I hereby release them from all liability arising from their responses and comments made in good faith and without malice.

 

Signature________________________________________________________
 
Name (print)______________________________________________________
 

Date Signed:_________________________________

Michigan Conference United Church of Christ VISION

Outdoor Ministries

 

It is the policy of the Michigan Conference United Church of Christ, VISION to secure conviction criminal history information from the Michigan State Police and information concerning substantiated child abuse and neglect from the records of the Michigan Department of Consumer and Industry Service Central Registry and the National Sex Offender Registry. 

 

In order to facilitate these checks, I voluntarily provide the following information:

 

Last Name___________________________

First Name__________________________MI__

 

Date of Birth___________________________ Race______________ Sex_________

 

Social Security Number_____________________________

 

Drivers License Number_____________________________

 

Previous Last Names__________________________________________________________

 

I understand that the above information is required by the Central Records Division of the Michigan State Police, Lansing, MI.  I authorize the Michigan Conference United Church of Christ VISION, to utilize the above information for the purpose of obtaining a conviction only criminal history file search and a substantiated child abuse and neglect search.  I further understand and authorize a yearly check each time I apply for a staff or volunteer position.

 

Signature_________________________________________________Date________________

 

 

 

Covenant Statement

Should my application be accepted, I agree to be bound by the guidelines and procedures of Camp Talahi and VISION.  I shall refrain from inappropriate conduct in the performance of my services on behalf of the camp and VISION, and to following the covenant statement.

 

q       To honor each child’s integrity and worth as a child of God.

q       To provide a nurturing environment for children and youth to grow socially, and spiritually.

q       To continue to grow and nurture my own personal faith.

q       To work in partnership with the professional staff, volunteers, and Christ as a part of the larger Christian community

 

I state that I have carefully read the guidelines and procedures outlines in the Code of Conduct and the above Covenant Statement and know the contents.  I sign this application as my own free act.  This is a legally binding agreement I have read and understand.

 

I further understand that if any of the information on this form is false, I will be removed upon such discovery from work with VISION Programs.

 

The information contained in this application is correct to the best of my knowledge.  I authorize the VISION Program Director or Site Manager to contact any references listed in this application to obtain information (including opinions) that they may have regarding my character and fitness for children or youth work.

 

Signature__________________________________Date______________________

 

 

I have been a member of ____________________(name of church)since _________.
                                          
I have never been convicted of, nor pled guilty or no contest to a crime. (Exclude convictions that have been sealed, expunged or legally eradicated, misdemeanor convictions for which probation was complete and the case we dismissed, or offenses about which inquiry is not permissible in this state)            True                 Not True
 
If NOT TRUE, please briefly describe the nature of the crime(s), the date and place of conviction and the legal disposition of the case. The VISION will not deny a position to any applicant solely because the person has been convicted of a crime. VISION , however, may consider the nature, date and circumstances of the offense, as well as whether the offense is relevant to the duties of the position applied for.
 
No civil lawsuit alleging actual or attempted sexual discrimination, harassment, exploitation, or misconduct; physical abuse; child abuse; or financial misconduct has ever resulted in a judgment being centered against me, been settled out of court, or been dismissed because the statute of limitations has expired.             True                 Not True
 
If NOT TRUE, give a short explanation of the lawsuit.  (Please indicate the date, nature, and place of the incident leading to the lawsuit; where the lawsuit was filed; and the precise disposition of the lawsuit.)
 
I have never terminated my employment, professional credentials, or service in a volunteer position or had my employment, professional credentials, or authorization to hold a volunteer position terminated for reasons relating to allegations of actual or attempted sexual discrimination, harassment, exploitation, or misconduct; physical abuse; child abuse; or financial misconduct.             True                 Not True
 
If NOT TRUE, give a short explanation. (Please indicate the date of termination; name, address, and telephone number of employer or volunteer supervisor; and nature of the incident(s) leading to your termination.)
 
Do you have a valid drivers’ license? Yes                 No
 
With respect to my driving record, I have not had my license suspended or revoked within the last five years due to reckless driving or driving while intoxicated and/or under the influence of a controlled substance. True                 Not True
 
Is there any fact or circumstance involving you or your background that would call into question your being entrusted with the responsibilities of the position for which you are applying?          Yes            No
 

If YES, provide a brief explanation.