For Office Use Only
______ Received
______ Interviewed
______ Contacted
______ Fingerprinted
ATTACH A PHOTO
 Training #1  Training #2
 Training #3  Training #4
Royal Family Kids Camp of South Dallas
Royal Family Kids Camp Sponsored by Southwestern Assemblies of God University and Trinity Church
Royal Family Kids Camps . 1200 Sycamore . Waxahachie, TX 75165 . 469-547-7352
www.southdallas.royalfamilykids.org . southdallas.rfkc@gmail.com
June 28 - July 3 • 2015
COUNSELOR/STAFF APPLICATION
Instructions: Please Print. All information is held strictly confidential. This form must be completely
filled out or will not be accepted. The information is vital to your acceptance and placement as a volunteer.
___________________
Date
_________________________
Current Drivers License #
____________________________
Social Security #
(a photocopy of license must
accompany application)
___________________________________________________________ M or F______/_____/_________
Last Name
First Name
Sex
Birthdate
__________________________________________________________________________/____________
Street (address where you are living now or where you will be living this summer)
Age
Marital Status
______________________________________________________________________________________
City
State
Zip
____________________________________________________
Email address (check email often this is how we will contact you)
________________________________
Facebook ~ name you use on FB
______________________________________________________________________________________
Occupation
Name of Employer
Number of years
How long have you lived in [state]? ______Years and ______ months
one year, list your complete addresses for the last five years:
If you have lived in [state] for less than
(_______)____________________________________________________
Cell Phone
(we need a good number we can contact you this summer)
_________________________________________________________________(______)______________
Emergency Contact
Relationship
Phone
Page 1 of 5, Document1, 5/07
T-Shirt Size:  Adult Small  Adult Medium  Adult Large  Adult X-Large  Adult XX-Large
Do you have certification in the following?  CPR  First Aid
 Life Guard  Nurse
3X
 EMT
Do you have previous training or background in dealing with abused, neglected or abandoned children?
 No  Yes. In what way:_______________________________________________________________
(Use back of paper if needed)
Were you a victim of abuse, neglect or abandonment as a minor?  NO  YES,
 Yes, but I would prefer to discuss this in person.
Please Clarify: _____________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Please describe why you wish to be a counselor for abused kids (use the back for space if necessary)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
MEDICAL HISTORY
Do you have any medical conditions?  NO  YES, if yes please describe:
______________________________________________________________________________________
Do you take any medications?  NO  YES, please list medicine, reason and any side effects:
______________________________________________________________________________________
Have you had any serious illness or injuries in the last three years?
 NO  Yes, please list:
Have you any physical handicaps or conditions preventing you from performing any type of activity?
 NO  YES, please list
Page 2 of 5, Document1, 11/12
RECORD OF EDUCATION
High School Name: ___________________________________________Date of Graduation:____________
College: ________________________________Major:_______________Date of Graduation:____________
Other: _________________________________Major:________________Date of Graduation:____________
PERSONAL REFERENCES (not former employers or relatives)
1. ____________________________________________________________________________________
Name
Address
Phone
2. ____________________________________________________________________________________
Name
Address
Phone
3. ____________________________________________________________________________________
Name
Address
Phone
Please be sure we will be able to reach your references and that their address and phone number are
correct. You must have 3 references with their complete address and phone number or your application will
not be accepted.
________________________________________________________________________________________
For Office use only
Reference 1__________________________________________________________________________
__________________________________________________________________________
Reference 2__________________________________________________________________________
__________________________________________________________________________
Reference 3__________________________________________________________________________
___________________________________________________________
Other____________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________
Page 3 of 5, Document1, 11/12
PERSONAL PROFILE
Have you committed your life to Jesus Christ?  NO  YES Where & When:__________________
What church do you presently attend? ____________________________ How long? ______ Yrs. _______ Mos.
Pastor’s Name: _____________________________________Church Phone #:_______________________
Do you have any previous experience working with children?  NO  YES, please describe:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Do you have any previous experience working with abused children?  NO  YES, please describe:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Do you feel you could lead 15-minute devotion with your campers with material we provide?  YES  NO
Please circle all the words below which you believe accurately describe you:
Timid
Gentle
Impatient
Modest
Nervous
Loving
Tactful
Mature
Sarcastic
Patient
Angry
Deliberate
Congenial
Compassionate
Stubborn
Kind
Studious
Selfish
Secure
Considerate
Abrasive
Trustworthy
Motivated
Verbal
Organized
Impulsive
Intelligent
Insecure
Relaxed
List below, five strengths and five weaknesses you have in working with children (please be specific)
Strengths
1._____________________________________________________________________________________
2._____________________________________________________________________________________
3._____________________________________________________________________________________
4._____________________________________________________________________________________
5._____________________________________________________________________________________
Weaknesses
1._____________________________________________________________________________________
2._____________________________________________________________________________________
3._____________________________________________________________________________________
4._____________________________________________________________________________________
5._____________________________________________________________________________________
I would prefer my campers to be:  7 Yrs Old  8 Yrs Old  9 Yrs Old  10 Yrs Old  11 Yrs Old
Page 4 of 5, Document1, 11/12
Have you ever been arrested for a criminal offense?
 NO
 YES
Have you ever been convicted of or plead guilty to a crime?
 NO
 YES
Have you ever been arrested for sexual misconduct?
 NO
 YES
Have you ever been convicted of or plead guilty to sexual misconduct?
 NO
 YES
Have you ever taken drugs other than prescription drugs?
 NO
 YES
Do you currently:
use tobacco  NO
 YES use alcohol  NO
 YES
use drugs  NO  YES
If you answered “YES” to any of the above please explain on the reverse side of this form.
Applicant’s Statement
The information contained in this application is correct to the best of my knowledge. I authorize any references or
churches listed in this application to give you any information (including opinions) that they may have regarding
my character and fitness for children or youth work. In consideration of the receipt and evaluation of this
application by Trinity Church, I hereby release any individual, church, youth organization, charity, employer
reference, or any other person or organization, including record custodians, both collectively and individually from
any and all liability for damages of whatever kind or nature which may at any time result to me, my heirs, or
family, on account of compliance or any attempts to comply, with this authorization. I waive any right that I may
have to inspect any information provided about me by any person or organization identified by me in this
application.
I further state that I have carefully read the foregoing release and know the contents thereof and I sign this release
as my own free act. This is a legally binding agreement which I have read and understand.
Please be advised that a criminal history check will be requested from the state(s) of Texas and that listed in your
address (as authorized by state law).
If I am accepted as a counselor or staff member, I will:
1. Attend ALL hours of training; (New volunteers must complete 12 hours; Returning volunteers, 8 hours)
2. Participate in the entire week of camp (see schedule below)
TRAINING: Saturday, April 11 (breakfast and lunch provided)
New volunteers: 8:00am-5:00pm
Returning volunteers: 12:00pm – 5:00pm
BASIC CAMP SCHEDULE: Begin on Sunday, June 28, 8:30am; End on Friday, July 3, 7:30pm
Basic Sunday Schedule (June 28): Arrive at Trinity Church at 8:30am. We will all attend the 9:00am service in order to be
“commissioned” in front of the church. We will then attend only the first half of the 11:00am service for commissioning. After
departing from the second service, we will leave Trinity Church and make our way to McCafferty Hall at SAGU, where we will
have lunch at 12:30pm and the remaining of our training from 1:00-4:00pm. We then set up the camp
Basic Friday Schedule (July 3): After arriving back at Trinity Church with the campers, we will say “Good-bye” and then
share in a dinner, the “Welcome Home” dinner (which will end at 7:30pm)
______________________________
Print Name
______________________________________ _________________________
Signature
Date
______________________________
Witness Name
______________________________________ _________________________
Witness Signature
Date
Please submit your completed form by February 13th through one of these methods:
1. Mail to the address listed at the top of the first page;
2. Deliver to the office of the camp director, Darren Daugherty, Scheaffer Building #2241, SAGU;
3. Deliver to the office of the assistant camp director, Matt McKay, Children’s Center, Trinity Church.
Page 5 of 5, Document1, 11/12