2019 Midwest Youth Camps Counselor Application
Thank you for applying to be a counselor at this summer's Midwest Youth Camps.

Your application will be reviewed and we will contact you to let you know if you've been selected to serve or not. Application does not guarantee acceptance as only a certain number are needed. We typically notify applicants by the end of May. If you need an earlier decision because of employment or other reasons, contact Heidi Ammons at heidi@chicagochurch.org.

INSTRUCTIONS: Review the entire application before you begin so you know what information is required.

Email address *
COUNSELOR INFORMATION
First Name *
Your answer
Middle Name *
Your answer
Last Name *
Your answer
Gender *
Address *
Your answer
City *
Your answer
State *
Your answer
ZIP *
Your answer
Birth Date *
MM
/
DD
/
YYYY
Cell Phone *
Your answer
Grade in School (if High School)
Your answer
T-Shirt Size *
Parent Name
For applicants under 18 years old only
Your answer
Emergency Contact *
Your answer
Emergency Contact Phone *
Your answer
Are you a member of an ICOC church? *
Which church are you a member of? *
Your answer
Which Ministry Center (Chicago Only)?
Your answer
What year were you baptized? *
Your answer
Your Ministry Leader's Name *
Your answer
Your Ministry Leader's Phone Number *
Your answer
Number of years worked as a counselor for the Midwest Youth Camps run by the Chicago Church of Christ *
Your answer
Additional experience working with youth
Your answer
Special skills/qualifications (nurse, lifeguard, CPR trained, etc.)
Your answer
List any special talents, instruments you play or if you lead songs
Your answer
SELECT CAMP SESSION
If you are able to volunteer for multiple sessions, please complete separate counselor applications for each.
Discover Camp ... July 28-Aug 3... Grades 5th-7th
Explore Camp ... July 21-27 ... Grades 8th-9th
Quest Camp ... July 14-20 ... Grades 10+
Camp Session *
REFERENCES
If you have a NON-CHURCH reference for any experience you have had in the past 12 months working with youth, please include the information below. Please notify each that you are using them as a reference.

If you don't have a NON-CHURCH reference for working with youth in the past 12 months, leave this section blank. Having a reference does not impact our decision.

Organization Name
Your answer
Organization - Address, City, State, ZIP
Your answer
Organization - Contact Name
Your answer
Organization - Contact Phone Number
Your answer
Organization - Dates of Service
Your answer
Organization - Type of Service
Your answer
BACKGROUND QUESTIONNAIRE
As part of the screening process, you'll also receive an email from our background check provider, Protect My Ministry, which will require you to supply additional information to confirm your identity -- including your social security number.
Why do you want to be a camp counselor? *
Your answer
Have you ever been disciplined for your work with children? *
If yes, explain.
Your answer
Have you ever been convicted of or pleaded guilty to a crime? *
If yes, explain.
Your answer
Have you ever abused or molested a child? *
If unclear, seek legal counsel
Is there any matter that may disqualify you from serving as a camp counselor? *
Your answer
MEDICAL INFORMATION
Health Information *
Please identify any chronic or recurring illness/condition. Or write "none"
Your answer
Allergies *
Medications, food, environmental. Or write "none"
Your answer
List of Medications *
Please list all medications -- prescription and non-prescription. Bring the medication in the ORIGINAL PACKAGE/BOTTLE that identifies your name, prescribing physician, name of drug, dosage and frequency. Or write "none"
Your answer
RELEASE
Should it be necessary for me to receive medical attention/treatment while participating in these activities, I hereby give my permission for the person(s) leading or directing these activities to render medical attention or administer medical treatment, as the physician/medical professional deems appropriate and necessary. I also give my permission for the person(s) leading or directing these activities to use their best judgment to otherwise render any assistance (i.e. First Aid, CPR, etc.) in the event of injury or illness.

I understand that the Chicago Church of Christ or any person(s) leading or directing these activities has no insurance coverage for medical or hospital costs for me, which are associated with injury or illness occurring in the course of these activities (unless the participant is already covered under the church’s employee health plan). Therefore, any costs incurred for such medical attention/treatment shall be my sole responsibility.

I further authorize any references or churches listed in this application to give the Chicago Church of Christ any information (including opinions) that they may have regarding my character and fitness for children or youth work. In addition I authorize the Chicago Church of Christ to do a background check on me at their discretion. In consideration of the receipt and evaluation of this application by the Chicago Church of Christ, 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.

Should my application be accepted, I agree to be bound by the Bylaws and policies of the Chicago Church of Christ and to refrain from unscriptural conduct in the performance of my services on behalf of the church. The information contained in this application is correct to the best of my knowledge. 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.

Applicant: Have you carefully read and accepted the forgoing release? *
Parent/Guardian: Have you carefully read and accepted the forgoing release?
Required for applicants under 18 years old. Over 18 leave blank.
A copy of your responses will be emailed to the address you provided.
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