First Name * Last Name *
Address *
City * State * Zip Code *
Telephone *
Driver's License #
Date of Birth * Place of Birth
Email address *
Shirt Size small medium large extra large * Male/Female female male *

1. List any cities and states in which you have lived, any denominations or churches of which you have been a member, including addresses, and all previous church service, volunteer or paid, you have provided since you were 17 years of age. Include approximate dates.

2. List all your previous non-church work, volunteer or paid, and reason for leaving. Include approximate dates, organization's name and address, type of work you performed, name of supervisor and phone number, if known.

3. Are you certified in either of the following? lifeguard ropes course facilitator

4. Do you consider yourself a positive role model for children?  Yes No

5. Please provide the names and phone numbers of three personal references not related to you.

              1. Name Telephone number

              2. Name Telephone number

              3. Name Telephone number

6. Because Camp Copass cares for children and young people and desires to protect them we ask you to please answer the following questions. We understand that the following questions are personal and we will protect your privacy.

A. Are there any reasons, including those that are physically or mentally health related, that might keep you from effectively working with children or youth, or that might cause a child potential harm?  Yes No

B. Have you ever been charged with, indicted for, or pled guilty to a crime? Yes No

C. Have you ever been charged with, indicted for, or pled guilty to an action prohibited by the Texas Family Code, or a similar code in any state? Yes No

D. Have you ever been known by any other legal name?   Yes No

              If yes, please list all other names including maiden name:

E. Would you be willing to be fingerprinted? Yes No

If you were personally a victim of child abuse we require that you make it know to the Camp Administrator. Admitting you were a victim will not automatically disqualify you from service. Your confidence will be respected and appreciated. The information contained in this application is correct to the best of my knowledge. I authorize Camp Copass to obtain information from references and churches listed herein. I also 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 Christian camp work. In consideration of the receipt and evaluation of this application by Camp Copass, I hereby release any individual, church, children's organization, charity, employer, reference, or any other person or organization, 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 Camp Copass and to refrain from unscriptural conduct in the performance of my services on behalf of the camp. I understand that Camp Copass desires to protect those who use their facilities and therefore give my permission for the Camp Administrator to conduct a criminal background check on me. I further state that I have carefully read the foregoing release and know the contents thereof; and sign this release as my own free act.

I have read the camp staff rules *

I will allow Camp Copass to add me as a friend on Facebook or other social networking site for full profile reviewing purposes.   Yes No *

Electronic Signature: *

Date: *