Sardis Lake Christian Camp

2016 Camp Volunteer Staff Application

MISSION
The mission of SLCC is to provide a Christian environment for young people to grow in wisdom,
knowledge, and understanding of the gospel of Jesus Christ. We also want the children to experience
the joy of summer camp in the same Christian environment. Every effort is made by the board of
directors, directors, counselors, and staff to make this mission a reality. Our motto is "Training young
people today to be Christian leaders tomorrow."

step 1: please mark which camp(s) you are applying to attend as staff

Session 6
Kick-off Week
Session 1
Session 2

May 29 - June 4
June 5-11
June 12-18
June 19-25

Session 3
Session 4
Session 5
Kids Camp

June 26 - July 2
July 3-9
July 10-16
July 17-19

step 2: please complete with counselor/staff information

All employees and volunteers associated with staff positions for Sardis Lake Christian Camp
must complete this form. The following information is required to run a national background
check and must be completed in its entirety
First Name
Middle Name
Last Name
D.O.B. MM/DD/YYYY

Sex

SSN

Present Mailing Address

City

State

How long have you been at the above address?

Home Phone

Cell Phone

Email Address
Name of Congregation You Attend
City

State

Please turn form over and continue on page 2

Zip

step 3: MEDICAL INFORMATION

It is necessary that we have an accurate history in the event that emergency treatment is required. All
information is confidential. This information MUST be turned in to the Session Medical Staff upon your arrival at
camp. ALL medications brought to camp MUST be given to the Session Medical Staff, to be locked in medical
cabinet. NO medications of any type are to be in the cabins.

Insurance Carrier
Insurance Policy Number
Insurance Group Number
Insurance Card Number
Policy Holder's First Name
Policy Holder's Last Name
Insurance Carrier Number

Have/Do you have any of the following:

Heart Trouble
Diabetes
Pregnancy

Ear Trouble
Food Allergy
Other

Asthma
Drug Allergy

List any allergies (medication, food, etc):

MM/YY
Date of Last Tetanus Shot:

Blood Type

Please include any other medical information that may be of importance:

Emergency Contact Name

Relationship to Emerg Contact

Phone

Please continue on page 3

Convulsions/Epilepsy
Hernia

step 4: CERTIFICATION / CONSENT FOR CRIMINAL BACKGROUND CHECK / AUTHORIZATION /

WAIVER / RELEASE / INDEMNITY/APPLICANTS SIGNATURE:
CHILD ABUSE STATEMENT
Sardis Lake Christian Camp (SLCC) and its affiliates have a great deal of concern about the safety and abuse of children. As a person who is interested in the well being
of children, we believe you are entitled to know how our organization is dealing with this critical issue. In addition, as an applicant for a volunteer/staff position with
our organization, you need to know the measures we employ to protect children in our care, as well volunteers/staff, from this serious problem.
SLCC has initiated this safety program and it is our intent to make every reasonable effort to deny from participation any person who has been convicted of a crime of
violence or a crime against another's person that would bring unnecessary risk to the health or safety of SLCCs participants. We will not tolerate the abuse of any child
and will make an active effort to prevent child sexual abuse in our programs. We attempt to screen out molesters through a background check. We try to structure our
activities so that volunteers/staff are not left alone with children. We take any allegations by children and others very seriously. We will refer allegations to the State
law enforcement authorities for investigation and will fully cooperate in any investigation.
MEDCIAL RELEASE
I understand that should a health emergency arise, I hereby give permission to the physician selected by the Camp Director to hospitalize, secure proper treatment for,
and to order injection, anesthesia or surgery for myself.

CERTIFICATION / CONSENT FOR CRIMINAL BACKGROUND CHECK / AUTHORIZATION / WAIVER / RELEASE / INDEMNITY
I certify that all of my statements on this application, the information provided, and attachments hereto, are true and complete to the best of my knowledge. I also
certify that I have not withheld any information that would affect my application unfavorably, if disclosed. I understand that any omission of facts or misrepresentation
will result in my elimination from consideration for any volunteer or staff position with Sardis Lake Christian Camp (SLCC) or its affiliates or, following acceptance of
service, may be cause for the immediate termination of my relationship with SLCC. I further certify that I understand the intent of SLCC is to deny a position to anyone
convicted of a crime of violence or a crime against another's person.

I acknowledge that SLCC or its affiliates will, and I hereby give my unconditional permission to SLCC and its affiliates to, inquire as deemed necessary into my prior
employment, experience, relationships with others and background, including criminal background checks which may contain arrest and conviction data, plea bargains
and any type of probation including deferred adjudication or "pre-trial diversion." I give my permission for Sardis Lake Christian Camp to obtain information relating to
my criminal history record from a background check vendor and/or licensed private investigator. I understand that this information will be used, in part, to determine
my eligibility for a staff / volunteer position(s) with this organization. I also understand that as long as I remain an employee or volunteer here, the background history
checks may be repeated at any time. I understand that a procedure is available for clarification and that I will have an opportunity to review the criminal history if I
dispute the record as received.
I further agree to conform to the rules, regulations, and policies of SLCC and I understand that my service/employment and compensation, if any, can be modified or
terminated, with or without notice or cause, at any time, at the option of either SLCC or myself. I understand that no representative of SLCC has the authority to enter
into any agreement for service/employment for any specified period of time, or to make any agreement contrary to the foregoing. I understand and agree that SLCC or
its affiliates may, in their sole discretion, decline to accept my application for volunteer/staff services with or without cause.

I understand that:
a. Sardis Lake Christian Camp (SLCC) may deny certification to any person who has been convicted of a felony, crime of violence or a crime against a person.
b. If applying for an employment or volunteer position with SLCC, the information, which I have furnished, on this form is subject to verification, which may include a
criminal history check.
c. This disclosure statement must be updated annually.
During the application process and at any time during the tenure of my employment/volunteer commitment with the aforementioned organization, I hereby authorize
the procurement of a criminal background report. This report may be compiled with information from courts record repositories, departments of motor vehicles, or
other entities and business that provide such information, or any other source required to verify information that I have voluntarily supplied.
By agreeing below I hereby release all persons, companies, corporations or individuals from all liabilities and responsibility that may result from providing the
information set out herein and related to the procurement of a criminal background check.
I declare under penalty of perjury under the laws of the state of my jurisdiction that the information is true and correct.

I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE CERTIFICATION / CONSENT FOR CRIMINAL BACKGROUND CHECK /
AUTHORIZATION / WAIVER / RELEASE / INDEMNITY, AND THAT I ACCEPT AND SIGN THIS FORM VOLUNTARILY.

Applicant Name (Print)

Applicant Signature

Date

Witness Name (Print)

Witness Signature

Date