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ROCKY MOUNTAIN HONORS CAMP

VOLUNTEER APPLICATION 7931 S. Broadway #163 ▪ Littleton, CO 80122 ▪ 303-552-6537

Position Preference 1st choice: 2nd choice:

Adult Shirt Size:

HS Counselor HS Counselor

JV Counselor JV Counselor

___S

___M

Music Music

___L

___XL ___XXL

Photographer Photographer

Audio/Visual  Staff Audio/Visual

Personal Information Awana Club Status:

___I am Currently Active

___I am Currently Inactive

___I have not been a Leader

Applicant’s Full Name ________________________________________Date of Birth ____________ Age ________ Name/nickname you prefer ____________________________

___Male ___ Female

___Married ___Single

Address __________________________________________________ City/State/Zip ________________________ Main Contact Phone _____________________ Email ________________________________________________ Have you earned your Awana Citation ___Yes

___No

Personal References Required References: 1) Pastor

2) Commander 3) Friend (non-family/3 years or more)

1) Pastor _____________________________________________________________ Years Known _____________ Phone ___________________

Email _________________________________________________

2) Commander ________________________________________________________ Years Known _____________ Phone ___________________

Email _________________________________________________

3) Friend _____________________________________________________________ Years Known _____________ Phone ___________________

Email _________________________________________________

Please give a Reference Questionnaire to each Person. Consider attaching a stamped/addressed envelope.

Your Church Information Home Church ____________________________________________ Main Phone __________________________ Church Address __________________________________________ City/State/Zip _________________________

Your Current Awana Club Awana Church ___________________________________________ Main Phone ___________________________ Church Address ___________________________________________ City/State/Zip _________________________ Awana Club Experience (in years) Puggles ____ Cubbies ____ Sparks ____ T&T ____ Trek ____ Journey ____ Have you been a camp counselor before? ___No

___Yes How many years? _________

Emergency Contact Information In case of emergency, please contact one of the people listed below: Name ________________________________________________________________________ Phone _____________________________ Address + city/state/zip _____________________________________________________________________________________________ Name ________________________________________________________________________ Phone _____________________________ Address + city/state/zip _____________________________________________________________________________________________ RMHC 2016 Volunteer Application – Page 1 of 4

Personal Testimony 1) 2) 3) 4)

Please explain when and how you received Jesus Christ as your personal Lord and Savior; Share a couple of significant steps of growth in your current relationship with Jesus Christ; Describe some of your ministry involvement. Please state your view of speaking in tongues.

________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________

By signing below: I testify that all of my given answers are true and accurate as far as I understand them to be. I authorize Rocky Mountain Honors Camp to investigate my references. I authorize Rocky Mountain Honors Camp to proceed with a background check by the State of Colorado. I testify to my understanding that this application for staff/counselor in no way guarantees my position at camp. I testify to follow all of Rocky Mountain Honors Camp’s policies and procedures if I am chosen as a staff/counselor. I understand that counselors/staff are volunteers only, and I have no expectation of compensation of any kind, of workers’ compensation, unemployment, health or other insurance coverage, or employee benefits; and that RMHC can terminate my volunteer relationship at any time, or for any reason, without prior notice to me. Camp is required on our staff Application to include the below perjury statement. This statement applies to your Application and any other forms you may have filled out this year. “Any applicant who knowingly or willfully makes a false statement of any material fact or thing in this Application is guilty of perjury in the second degree as defined in section 18-80503, C.R.S, and, upon conviction thereof, shall be punished accordingly.” I testify that all of my given answers on my staff Application are true and accurate as far as I understand them to be.

Signature (required for acceptance) __________________________________________________ Date______________ RMHC 2016 Volunteer Application – Page 2 of 4

CONSENT AND RELEASE OF LIABILITY FORM THIS DOCUMENT CONTAINS A RELEASE OF LIABILITY. YOU ARE ADVISED TO REVIEW IT CAREFULLY.

Volunteer/Staff Name______________________________________________________ Date of Birth _________________ I understand and agree that participation at Rocky Mountain Honors Camp (“Camp”) is a privilege to which I am not otherwise entitled. In consideration for that privilege, I am signing this Consent and Release of Liability.

RELEASE OF LIABILITY

Prior to participation in Camp activities, I acknowledge that my involvement in the Camp may involve risk of property damage and of personal injury, illness, or even death, including but not limited to the risks arising from transportation-related activities, recreational activities, accidents in the outdoors and rustic facilities, adverse weather conditions, and injuries and illness as a result of food-borne illnesses and allergic reactions. In addition, I understand that there may be other risks inherent in Camp activities of which I may not be presently aware. By signing this Consent and Release of Liability, I warrant that I am fully capable of safely participating in all Camp activities, and I expressly assume all risks of my participation, whether such risks are known or unknown to me at this time. I further generally release Rocky Mountain Honors Camp, Covenant Heights Camp and Retreat Center, and their directors, officers, employees, volunteers, or agents, and other guests at the Camp, from any and all claims that I may have against any of them as a result of property damage or personal injury, illness or death as a result of participation in Camp activities, whether on or off Camp grounds. I agree that this release includes the ordinary, special and inherent risks described above, and other risks that I may not foresee or be aware of at this time. This Consent and Release of Liability is given on behalf of myself, and the heirs, family, estate, administrators, executors, personal representatives and assignees of me.

PHOTO/MEDIA RELEASE

I understand that, while I am participating in Camp activities, photographs, film, audio recording and videotape of me may be taken for use in brochures, videos, releases to the press, and various RMHC publications and other work product. I do hereby irrevocably grant RMHC permission to record, display and/or reproduce my name (first name only), likeness and voice on audio and/or video tape, film or other media, to edit and otherwise modify such media at its discretion, to incorporate the media into any work product, and to use or authorize the use of such media and any portion thereof in any manner or media or by any means, methods or technologies now known or hereafter to be known.

CHILD ABUSE REPORTING

Under the “Child Protection Act of 1987” (C.R.S. 19-3-301) in the Colorado Children’s Code, childcare center workers are required to report suspected child abuse or neglect. The law at 19-3-304 states that if a child care worker has “reasonable cause to know or suspect that a child has been subjected to circumstances or conditions which would reasonably result in abuse or neglect shall immediately report or cause a report to be made of such fact to the county department or local law enforcement agency.” “Abuse” or “child abuse or neglect” means an act or omission in one of the following categories which threatens the health or welfare of a child: skin bruising, bleeding, tissue swelling, or death; any case in which a child is subjected to sexual assault or molestation, sexual exploitation, or prostitution; any case in which a child is in need of services because the child’s parents, legal guardian, or custodian fails to take the same actions to provide adequate food, clothing, shelter, medical care, or supervision that a prudent parent would take. If, at any time, a staff member reasonably suspects child abuse, it is the responsibility of that staff member to report or to cause a report to be made of this suspicion to the local county department of social or human services at (970) 330-0797 or (970) 3306300, or the local police department. It is not the staff’s roll to investigate suspected abuse – only to report it. Persons who make a good faith report are immune from civil and criminal liability. Additionally, the law provides for the protection of the identity of the reporting party. A child care worker who fails to report suspected child abuse or neglect commits a class 3 misdemeanor and will be punished as provided in section 18-1-106, C.R.S. The staff person could also be liable for damages “proximately caused thereby.” I have read and understand the above requirements concerning my responsibility regarding child abuse reporting. Signature __________________________________________________________ Date ________________________ RMHC 2016 Volunteer Application – Page 3 of 4

VEHICLE KEY – EMERGENCY PRODEDURE

If you drive to camp please TAKE AN EXTRA KEY to give to the Camp Director. Keys will be placed in an emergency box, and in the event of an emergency and access to your vehicle is required (to move your vehicle, retrieve something from your vehicle, etc.) the emergency key will be used.

ARBITRATION

I further expressly agree to resolve any claims or complaints arising out of this agreement with my participation in the Rocky Mountain Honors Camp through mandatory mediation and, if necessary binding arbitration with the Institute for Christian Conciliation (I.C.C.), associated with Peacemaker Ministries. If any claim or complaint cannot be resolved through mediation with the I.C.C., I expressly waive any right to sue Rocky Mountain Honors Camp, their directors, officers, employees, volunteers, or agents, and other guests at the Camp, and consent to be bound by any matter decided by arbitration with the I.C.C. I further agree that I may assist in selecting an I.C.C. approved mediator or arbitrator. All costs for mediating or arbitrating with the I.C.C. will be shared equally by the parties. I represent that I am at least eighteen (18) years of age and I am under no mental or legal disability, which would prevent me from signing and executing this agreement. I further represent that I have read (or have had read to me) and understand the terms of this agreement. Signature__________________________________________________

Date________________

HEALTH INFORMATION Health Insurance ________________________________________________________ Phone No. ____________________ (Please attach a copy of the front and back of your insurance card) Doctor’s Name _____________________________________________________________ Phone # ____________________ Office Address _________________________________________________________________________________________

HEALTH HISTORY Are you currently taking any prescription medication? ____Yes If yes, indicate prescription(s)

____No

________________________________________________________________________________________________

Drug Reactions/Allergies: _________________________________________________________________________________ Special Diet: ___________________________________________________________________________________________ Special health/behavior needs/physical limitations: _____________________________________________________________ Current or recent exposure to contagious/infectious disease: ___Yes

___No If yes, please explain ________________________

CURRENT PHYSICAL (must be within 24 months of camp date) ___On File ___ Attached ___Will Send on Acceptance MEDICAL/LIFEGUARD CERTIFICATIONS Are you CPR/Lifeguard Certified? ___CPR

___Lifeguard

___Yes Current through (date) _____

___No

Any other medical/emergency certifications? Please list/state if you are current _____________________________________

CONSENT FOR MEDICAL TREATMENT

In the event of an emergency I hereby consent in advance to the designated leaders of Rocky Mountain Honors Camp (RMHC) and to the physicians or hospital selected by them to render first aid treatment as in their judgment is reasonably necessary, but not limited to, hospitalization, diagnosis including taking specimens and x-rays, giving blood transfusions and medications, anesthesia, and surgery for (print name) ___________________________________________________. I release Rocky Mountain Honors Camp and the Host Camp leaders and staff from any and all claims, loss, cost, damage or expense arising out of or from any accident or other occurrences causing injury to any person or property. By signing below, I acknowledge that this document has been read and understood by me, and also represent that all information provided is accurate. Signature _____________________________________________________

Date ________________________

Witness ______________________________________________________

Date ________________________

RMHC 2016 Volunteer Application – Page 4 of 4

Please use a pen and print clearly

ROCKY MOUNTAIN HONORS CAMP 7931 S. Broadway #163 ▪ Littleton, CO 80122 ▪ 303-552-6537

REFERENCE QUESTIONNAIRE

Applicant’s Full Name_________________________________________________________________

Reference must be mailed by the party completing the Questionnaire.

Please MAIL completed form to RMHC within two weeks of receipt. Do not give to Applicant. Thank you! The above named individual is applying to serve as a counselor for Rocky Mountain Honors Camp. As part of the application process letters of reference are obtained. Thank you for your time in completing this reference!

1. What is your relationship with the applicant?

Pastor

 Friend

Commander

2. How long have you known the applicant?  Less than 1Year

1 - 3 Years

3. How familiar are you with the applicant? Distant Acquaintance

More than 3 Years

Acquaintance

Close Friend

4. How does the applicant relate to others? Frequent Problems Occasional Problems Rarely a Problem Very Well 5. Would you consider the applicant to be a team player?

Yes

6. Have you observed the applicant interacting with children? 7. Does the applicant get along well with children?

Yes

No

Yes

If you need additional space for an answer please use the back of this form.

No

No

Please explain _______________________________________________________________________________________ 8. Please rate the emotional maturity of the applicant.

Mature

Immature

Please explain ______________________________________________________________________________________ 9. Have you ever witnessed the applicant losing his/her temper?

Yes

No

Please explain ______________________________________________________________________________________ 10. Can the applicant handle change, or is he/she flexible?

Yes

11. Does the applicant frequently follow through on his/her commitments?

No Yes

12. To your knowledge, has the applicant ever had problems with drugs or alcohol?

No Yes No

13. To your knowledge, has the applicant ever been investigated, charged, arrested and/or convicted of child abuse or neglect, an offense involving actual or attempted sexual molestation of a minor, or an offense that would otherwise make him/her unsuitable for working with or in close proximity to children? No

Yes, please explain ___________________________

_____________________________________________________________________________________________________ 14. Would you recommend the applicant for work with children without any reservation? Yes

No, please explain _____

______________________________________________________________________________________________________ 15. Would you entrust your own children to this person?

Yes

No, please explain ______________________________

______________________________________________________________________________________________________ 16. Do you know of any circumstance that would make it inappropriate for the applicant to work with children?

Yes

No

If yes, please explain _____________________________________________________________________________________ 17. Do you know of any circumstance about the applicant that would compromise this ministry?

Yes

No

If yes, please explain _____________________________________________________________________________________ Signature ____________________________________________________________ Date ____________________ Print Name ________________________________________________ Main Phone _________________________ Address __________________________________________ Email _______________________________________ RMHC 2016 Volunteer App– Ref Letter

ROCKY MOUNTAIN HONORS CAMP 7931 S. Broadway #163 ▪ Littleton, CO 80122

Please mail reference to

ROCKY MOUNTAIN HONORS CAMP

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7931 S. Broadway #163 ▪ Littleton, CO 80122 ▪ 303-552-6537 Staff and Volunteers Residing Outside of Colorado Are Required To Have A Background Check Completed Each Year. Below is the Request and Authorization Form which allows us to perform the check. It is a separate form and is only viewed by the parties conducting the check (it is not attached to your general Application). THIS PAGE IS REQUIRED FOR OUT OF STATE VOLUNTEER APPLICANTS ONLY (Do not complete if you reside in Colorado)

Request for Criminal Records Check and Authorization Please read carefully before signing

I, the undersigned applicant, authorize Rocky Mountain Honors Camp to procure background information (also known as a “consumer report” and/or “ investigative consumer report”) about me. This report may include my driving history, including any traffic citations; a social security number verification; present and former addresses; present or former employer; and state sex offender records. I voluntarily and knowingly unconditionally release any name or unnamed informant from any and all liability resulting from the furnishing of this information. A photographic or faxed copy of the authorization shall be valid as the original.

Applicant’s Signature ____________________________________________________ Date ________________ Print Name (first, middle, last) _____________________________________________________________________ Other Names Used (alias, maiden, nickname) _________________________________________________________ Current Address _____________________________________________________________________________ City/State/Zip ________________________________________________ Length of Residency ____________ Date of Birth: mm/dd/yyyy ____ ____ /____ ____/____ ____ ____ ____

Gender: ___Male ___Female

Social Security Number: ____ ____ ____ - ____ ____ - ____ ____ ____ ____ Driver's License Number: ________________________________ State: ________

Statement of Criminal History 1. Have you ever been convicted of any felony, child abuse, or unlawful sexual offense, or ever been charged with the commission of an act of child abuse or unlawful sexual offense? ___No ___ Yes If yes, please attach an explanation with the conviction(s), date(s), and circumstance(s). 2. Have you ever been or are you currently being investigated by a governmental agency for the abuse or endangerment of children? ___No ___Yes If yes, please attach an explanation with the conviction(s), date(s), and circumstance(s). 3. Have you ever been denied the opportunity to work with children in any capacity? ___No ___Yes If yes, please attach an explanation with the conviction(s), date(s), and circumstance(s).

RMHC 2016 Volunteer Application – Out of State Addendum