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?*
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
We are often looking for interns with special skills or hobbies that could be beneficial during our summer camping program. Describe any additional certifications, talents, hobbies and/or skills that you bring to the summer camp program:*
Health Information
Note: health information is kept confidential between the applicant, camp staff supervisor, and the camp nurse. In case of an emergency, the camp staff supervisor and/or the camp nurse may share this information with emergency medical personnel as appropriate.
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
Recent illnesses, injuries or surgeries that may affect your ability to work (what/when):*
Other health related restrictions or information that may affect your ability to work:
Special dietary restrictions*
Church Information and Participation

The Camp and Conference Ministry for the Christian Church in Kansas 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)
Other ways I display mature faith and/or exercise my Christian faith
Personal Disclosure Statement

In accordance with the Child Protection Policies of the Christian Church in Kansas, all Disciples Center at Tawakoni staff and volunteers must fill out an application including references and pass a standard background check. (If any question below is answered yes, please explain.)
Have you ever been charged or convicted of a felony?*
- Yes
- No
Have you ever been charged with or convicted of any crime against children or other persons?*
- Yes
- No
Is there any other fact or circumstance in your background that should prevent you from being entrusted with the supervision, guidance, and care of children or youth?*
- Yes
- No
Did you answer yes to any of the above questions? Please explain your answer.
By checking this box I understand the Christian Church in Kansas will check state and federal criminal history data bases to confirm my suitability to serve.*
- Yes, I understand
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 (CCK), 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 the camping programs.

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 references 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 children and 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 a member of the Tawakoni 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 ministry leader and will abide by the policies pertaining to the CCK Outdoor Ministries program, and to the Ministerial Code of Ethics.
Signature
Date
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

Contact Information

Work and/or Education

Health Information

Church Information and Participation

Personal Disclosure Statement

References

Essay Questions

General Release and Signatures

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