1. Full Name (First, Middle, Last):

     If you prefer to be addressed by a nickname or shortened form, please indicate it here:

2. Mailing Address(es) and Telephone:

2b. Your e-mail address:

3. Birth Date:

4. Social Security Number:

5: Sex:

6. Height:

7. Weight:

8. Church Affiliation:

9. Staff Position(s) for which you are applying:  Below are listed Christikon staff positions. By each in which you may be interested, place a ranking of 1, 2 or 3, according to this ranking: 1="I'm most interested in this position"   2="I'm interested in this position, but it's not among my highest choice(s)"   3="I'm available for this position, but it's a lower priority for me".  Refer to the current description of staff positions. While staff often serve in several positions, each holds a primary designated position (e.g. counselor, cook, etc.)

10. Education.  List any educational institutions you have attended or are attending beyond high school, giving dates of attendance, major(s), and any degrees earned and the year in which they were awarded:

Are you currently a student?  □ Yes    □ No

If "Yes," what year are you considered at your current school?  □ 1     □ 2     □ 3     □ 4     □ Grad Student

11. Previous organized camp experience.  List any camps you have attended as a camper or with whom you have been employed. Give the name of the camp and the year(s) in which you attended. If you were part of a camp staff, also indicate the beginning and ending month/year of your employment, and the position(s) you held or the nature of your work, for each camp listed:

12. Employment Background.  List your work experience (other than camps) during the past five years, giving name of employer, dates of employment (beginning and ending month/year), and the position(s) you held or the nature of your work with each employer. If more space is needed, add rows or use another sheet of paper.

13. Your time availability:

    a. Are you able to attend the entire staff training period?    □ Yes    □ No    If "No," please specify and explain dates you would be unable to attend:

    b. Are you able to serve the entire basic camp season?    □ Yes    □ No    If "No," please specify and explain dates you would be unable to serve:

    c. Are you able to remain at camp until Labor Day?          □ Yes    □ No

    d. Are you able to arrive earlier than regular staff training?  □ Yes    □ No    If "Yes," please indicate the earliest date you could arrive:

14. Special skills and interests.  Please check or bold any that are applicable:

15. Health Care Certifications.  Please check or bold any that are applicable, listing expiration date after each:

Wilderness First Aid Wilderness First Responder CPR

Graduate Nurse Registered Nurse EMT

Other:

16. References.  List three personal references. If you have previously worked on a camp staff, your former camp director (or immediate supervisor) should be one of these. Ask each to complete the Reference Questionnaire and mail it directly to our office.  For each, list name, mailing address, telephone, and your relationship with that person (e.g. employer, teacher, etc.)

Name	Mailing Address	Telephone	Relationship

17. Additional information.  On a separate sheet of paper, please provide responses to the following:

a. Why do you want to be a part of the Christikon staff community?  What are your expectations for spending the summer with us?

b. In addition to those marked above, do you have other interests, skills, abilities or other qualities that could be resources for your work in outdoor ministry?

c. Describe your present life of faith. What and/or who have been the major influences on your growth in the faith?

d. Special considerations: Are you able to fulfill the essential functions of the position(s) for which you are applying? If your answer is "no," please explain. (If you are unclear about the essential functions, please contact us for a detailed description.)  If you wish, you may describe personal commitments, dietary restrictions, necessary reasonable accommodations or other personal situations that invite consideration. Also, if you currently follow a solely vegetarian diet, please describe your reasons for doing so, and indicate the degree of flexibility you are prepared to allow in your diet while at camp.

e. If there is anything else you would like to add, or if there are things you would like us to know in considering your application, please feel free to include them in your comments.

18. Photo. If you are unable to participate in an in-person interview, it would be helpful to have a recent photo of you.

19. Disclosure.  A form, "Voluntary Disclosure Statement/All Camp Staff," will be mailed to you when we receive your application.  Complete, sign and return it to us to complete your application.

20. Authorization, signature and date.

To the best of my knowledge, the information contained in this application is accurate. I hereby give permission to Christikon to verify the information in this application and to ask for references from my current and/or former employers and work supervisors and/or others whom I list a references.

Signature_________________________________________________________    Date_________________________________