First Presbyterian Church Meadville, Pennsylvania
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Royal Family Kids Counselor/Staff Application
Instructions:
Please fill out all the information on this form. The information is vital to your acceptance and possible placement as a counselor.
(
ALL
information is held strictly confidential)
*
Indicates required field
Name
*
First
Last
Age
*
Birth Date
*
Drivers License Number
*
Attach Photocopy of Drivers License
*
Social Security Number
*
Occupation
*
What do you do for a living?
Name of Employer
*
Number of Years
*
How many years have you worked there?
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Email
*
Provide an email address that you check often
Cell Phone
*
Be sure to provide the area code
Home Phone
*
Be sure to provide the area code
Bus. Phone
*
Be sure to provide the area code
Name of Emergency Contact
*
First
Last
Provide an emergency contact
Emergency Contact Phone
*
Relationship to You
*
Provide the relation of the emergency contact to you. (Mom, Dad, Aunt, etc..)
Marital Status
*
Single
Married
Separated
Dicorced
Widowed
Select one that best suits you
T-Shirt Size
*
Adult Small
Adult Medium
Adult Large
Adult X-Large
Adult XX-Large
Adult XXX-Large
Do you have a certification in the following?
*
CPR
First Aid
Life Guard
Nurse
EMT
Check all that apply
Please upload a picture of yourself
*
(CAMP USE ONLY)
Please describe why you wish to be a counselor for abused kids
*
Medical History
Do you have previous training or background in dealing with abused, neglected, or abandoned children?
*
Yes
No
What Training/Background
*
If you have had training or background in dealing with abused, neglected, or abandoned children, please provide in what way
Have you ever been abused, neglected, or abandoned?
*
No
Yes
Yes, but I would prefer to discuss this in person
Please Clarify
*
If you have been abused, neglected, or abandoned and are willing to talk about it, please do so below.
Do you have any medical problems?
*
No
Yes
Do you have any physical handicaps or conditions preventing you from performing any type of activity?
*
No
Yes
Please Describe
*
If you have any medical problems please list them here
Please Describe
*
If you have a physical handicap or condition, please describe it
Record of Education
High School Name
*
What high school did you attend?
Date of Graduation
*
When did you graduate?
College
*
If you went to college, put the college you attended below
What did you major in?
*
Date of Graduation
*
Other
*
What did you major in?
*
Date of Graduation
*
Personal References
(not former employees or relatives)
Name
*
First
Last
Email
*
Phone Number
*
Name
*
First
Last
Email
*
Phone Number
*
Name
*
First
Last
Email
*
Phone Number
*
Personal Profile
Do you attend a church?
*
No
Yes
If yes, what is the name of your church?
*
Do you have any previous experience working with children?
*
No
Yes
If yes, please describe
*
Lists 5 strengths you have in working with children
*
Lists 5 weaknesses you have in working with children
*
Check each word below that you believe accurately describes you
*
Timid
Tactful
Congenial
Secure
Organized
Gentle
Mature
Compassionate
Considerate
Impulsive
Impatient
Sarcastic
Stubborn
Abrasive
Intelligent
Modest
Patient
Kind
Trustworthy
Insecure
Nervous
Angry
Studious
Motivated
Relaxed
Loving
Deliberate
Selfish
Verbal
I would prefer my campers to be...
*
6 Years Old
7 Years Old
8 Years Old
9 Years Old
10 Years Old
11 Years Old
Have you ever been arrested for a criminal offense?
*
No
Yes
Have you ever been arrested for sexual molestation or sexual misconduct?
*
No
Yes
Have you ever taken drugs other than prescription drugs?
*
No
Yes
I currently use...
*
Tobacco
Alchohol
Drugs
Nothing
If you answered yes to any of the above questions, please explain
*
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 Our Father’s Children, Inc., 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 of 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.
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 of PA and others applicable as authorized by state law.
By signing my name, I hereby signify the above information is true and correct to the best of my knowledge
Your Name
*
First
Last
(You will be required to sign this statement in person during training)
Submit
Home
Visit Us
History
Who's Who
News & Events
Music
Study & Service
Contact Us
More...
Lifetouch Directory
Presbyterian: What's That?
Officers
Presbyterian Women
Architecture
Photo Gallery
