Counselor Registration "*" indicates required fields Have you been a counselor at NEBTC before?* Yes No What year(s) were you a counselor?Select all that apply 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 Thank you for your willingness to serve as a counselor at the New England Baptist Teen Camp, a ministry of State Line Baptist Church. Because each and every volunteer has the potential to impact children for good or for evil, we must ensure that all those participating maintain a Biblical standard of godliness in their personal behavior. We trust that you share our desire to protect the precious young people whom God has entrusted to us. Please fill out the screening form completely, taking care to answer each question truthfully and completely.Personal InformationName* First Last Social Security Number* Birthdate* Month Day Year Have you ever used any other names (such as a maiden name)?* Yes No Please list the other names you have used.*Are you over 18?* Yes No Current Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone*Home PhoneSpiritual QualificationsWhat church are you currently attending?* Briefly describe your salvation experience*Educational / Professional QualificationsFirst Aid Training?* Yes No First Aid - Date Completed* Month Day Year CPR Training?* Yes No CPR - Date Completed* Month Day Year Background InformationHave you ever been convicted of or plead guilty to committing a crime involving the abuse or endangerment of children?* Yes No We regret to inform you that you are not eligible to serve in our children’s ministry.Have you ever been or are you currently charged with committing a crime involving the abuse or endangerment of children?* Yes No Please explain the charges and situation*Have you ever been or are you currently being investigated by a governmental agency for the abuse or endangerment of children?* Yes No Please explain the details of the investigation*Have you ever been sued for negligence with regard to caring for or supervising children?* Yes No Please explain the details of the lawsuit*Personal ReferencesReference 1 - Name* First Last Reference 1 - Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Reference 1 - Phone*Reference 1 - Email* Reference 2 - Name* First Last Reference 2 - Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Reference 2 - Phone*Reference 2 - Email* Reference 3 - Name* First Last Reference 3 - Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Reference 3 - Phone*Reference 3 - Email* Church ReferenceChurch Name* Pastor's Name* Church Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Church Phone*Church Email* Disclosures and AgreementsConsent*I hereby certify that the information I have provided in this application is true and complete. I authorize State Line Baptist Church to verify the information I have provided on this application by contacting the references, and churches I have listed, by conducting a criminal records check, or by other means, including contacting others whom I have not listed. I authorize the references and employers listed in this application to give the church whatever information they may have regarding my character and fitness for the job for which I have applied. Furthermore, I waive any rights I may have to confidentiality. In consideration of the receipt and evaluation of this application by State Line Baptist 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 compliance or any attempts to comply, with this authorization. Should my application be accepted, I agree to abide by and be bound by the policies and the moral and spiritual teaching of New England Baptist Teen Camp, a group sponsored by State Line Baptist Church, and to refrain from unscriptural conduct in the performance of my duties on behalf of the New England Baptist Teen Camp, State Line Baptist Church, and its ministries. I have read this waiver and the entire application, and I am fully aware of its contents. I sign this consent freely and under no duress or coercion. I understand that any omission or misinformation in the application may result in the rejection of my application or my dismissal from service if I have already been given my position. I also consent to the use of this digital form, and my name in the field below represents my signature. I agree to the terms of this form.Digital Signature* First Last Today's Date* MM slash DD slash YYYY
