Summer Intern Application - Disciples Center at Tawakoni

Contact Information
Name*
First Middle Last
Birth Name or Alias*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How long have you lived at this address?*
Have you lived at this address less than 5 years?*
- Yes
- No
Prior Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone*
This phone is a*
- Mobile
- Home
- Office
Secondary Phone
This phone is a
- Mobile
- Home
- Office
Email*
Date of Birth*
MM slash DD slash YYYY
Place of Birth*
City, State OR Foreign Country
T-Shirt Size (Adult Sizes)*
- S
- M
- L
- XL
- XXL
Work and/or Education
List college or trade schools attended in the last 5 years in reverse order
Name of School*
Major/Area of Study*
Planned Grad Year*
Name of School
Major/Area of Study
Years Attended
Name of School
Major/Area of Study
Years attended
List work experience from the last 5 years in reverse order
Name of Employer*
Duties/Responsibilities*
Years worked:*
Name of Employer
Duties/Responsibilities
Years worked
Name of Employer
Duties/Responsibilites
Years worked
Describe any additional talents, hobbies and/or skills that you bring to the summer camp program:*
Health Information
Emergency Contact Name*
First Last
Relationship to Applicant*
Primary Phone*
This phone is a*
- Mobile
- Home
- Office
Secondary Phone
This phone is a
- Mobile
- Home
- Office
Email*
Person Responsible for Insurance Coverage*
First Last
Health Insurance Carrier*
Policy Number*
Group Number*
Insurance Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Personal Physician Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Date of Last Physical Exam (Month/Year)*
Height*
Weight*
Recent illnesses, injuries or surgeries (what/when):*
Restrictions on camp activities*
- None
- Strenuous Activities
- Swimming
Other information that would be helpful
Special dietary restrictions*
Date of last Polio Vaccine (Month/Year)*
Oral?*
- Yes
- No
Date of last Tetanus Shot (Month/Year)*
Allergies
- Hay Fever
- Asprin
- Sulfa
- Penicillin
- Tetanus Shots
- Dust
- Poison Ivy/Oak
- Bee/Insect Stings
- Other
If other, please explain
History of or presently under the care for:
Select all that apply
- Heart Condition
- Arthritis
- High Blood Pressure
- Bronchitis
- Appendicitis
- Low Blood Pressure
- Hernia
- Skin Ulcer
- Digestive Disorder
- Skin Disease
- Fainting
- Nervous Disorder
- Exhaustion
- Asthma
- Epilepsy/Seizures
- Diabetes/Hypoglycemia
- Tonsillitis
- Athlete's Foot
- Other
If other, please explain
Applicant Subject to:
- Homesickness
- Fainting
- Headache
- Sleepwalking
- Sore Throat
- Cramps
- Cold/Pneumonia
- Stomach Aches
- Hyperactivity
- Ear Aches
- Swimmer's Ear
- Exhaustion
- Tooth Aches
- Nosebleeds
- Bed Wetting
- Other
If other, please explain
Church Information and Participation

The C & C Ministry seeks leaders who model mature faith and who appropriately represent the Christian Church (DOC) tradition.
Church Membership (Church and Town)*
How long have you been a member?*
Please check all that apply*
- I attend worship
- I lead/teach a youth fellowship, Sunday School class, or Bible study at my local church
- I serve in other ways in my local church (explain below)
- I participate in Bible Study or Prayer group
- I display service to others (explain below)
How often do you attend worship?
- Frequently
- Some
- Seldom
Name of class/group you lead/teach
What other ways do you serve in your local church?
How often do you participate in Bible Study or Prayer group
- Frequently
- Some
- Seldom
How do you display service to others?
Other ways I display mature faith and/or exercise my Christian faith
Child Protection
Have you ever been convicted of child abuse, or of a crime involving actual or attempted sexual molestation of a minor*
- No
- Yes
If yes, please explain
References

Please list three persons who are familiar with your character as it relates to working with children/youth. Beginning 1999, Volunteer Application Form References will be kept on file and considered valid for a period of three (3) years. Include your pastor/youth pastor as one, please.
Pastor/Youth Pastor Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone*
This phone is a*
- Mobile
- Home
- Office
Secondary Phone
This phone is a
- Mobile
- Home
- Office
Email*
Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone*
This phone is a*
- Mobile
- Home
- Office
Secondary Phone
This phone is a
- Mobile
- Home
- Office
Email*
Relationship*
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone*
This phone is a*
- Mobile
- Home
- Office
Secondary Phone
This phone is a
- Mobile
- Home
- Office
Email*
Relationship*
Essay Questions
In 100 words or less, describe your faith story*
In 100 words or less, describe why you want to serve as a Summer Leadership Intern at Tawakoni*
In 100 words or less, describe what you plan to do in the next five years*
General Release and Signatures
I, the undersigned, certify that the information contained in this application is correct to the best of my knowledge. I understand that the Christian Church in Kansas, through the Camp & Conference Ministry, will be contacting persons or organizations named in this application to confirm my abilities and character appropriate for leadership in Church Camping programs, and will check state and federal criminal history data bases to confirm my suitability to serve.

I authorize any reference listed in this application to give any information they may have regarding my character and fitness for working around children, youth or others in the church. I release all such reference from liability for any damage that may result from furnishing such evaluations; and, I waive my right to inspect references provided on my behalf.

I understand that I am expected to be an appropriate moral role-model for youth, and I believe that I am capable of serving in that capacity. Further, I agree to participate in any training event(s) pertaining to my service as member of a Camp Staff sponsored by the Camp & Conference Ministry, CCK.

Should my application be accepted, I agree to abide by the best ethical behavior becoming of a minister/leader, and will abide by the policies pertaining to the Christian Church in Kansas Outdoor Ministries program, and to the Ministerial Code of Ethics.
Signature
Date
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

Contact Information

Work and/or Education

Health Information

Church Information and Participation

Child Protection

References

Essay Questions

General Release and Signatures

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