NAME Last Name * Frst Name * Middle ADDRESS Address * City * State * Zip Code Home Phone Cell Phone E-mail INTEREST Work Camp I am interested in working Children's Camp Camp Positions I am interested in working as Sports Director I am interested in working as a Sports Helper I am interested in working as an Assistant Counselor I am interested in working in Crafts I am interested in working as nurse I am interested in working as a Counselor I am interested in working as Other BACKGROUND Home Church Occupation Children Atending Camp My child is attending a camp Camp Attending Attending Jr. & Sr. High Camp Attending Boys & Girls Camp Attending Family Camp Certification ALS MINISTRY WSI CPR RN FIRST AID LIFEGUARD Age EXPERIENCE Describe previous experience working with children and youth: Worked a camp I have worked at an Illinois District Camp. Which Camp & When Where are you a member? What city is the church located in? Church history past 5 years: Explain your testimony of faith in Christ: HEALTH Communicable Disease I have or believe I have a communicable disease. If you have or believe you have a communicable disease, please send a physician's release and instructions about your camp involvement to the Illinois District Church of the Nazarene, P.O. 1054, Alton, Il 62002. Physical Activity Restriction Explanation List Prescription Medications RECOMMENDATIONS Please give the name of your pastor and one other person that may be contacted as a character reference. Pastor's Name Church Phone   Other Reference Relationship Phone I certify that to the best of my knowledge all the information on this application is true. I have read the camp policies and will abide by them and the religious principles of the Illinois District Church of the Nazarene and their board and officers. If deemed necessary by the camp or their agents, I grant my consent to a criminal history check and request from any Central Registry of known child abusers in consideration of my suitability to work with children. Consent I Agree I Disagree