Mr. Len Martin (614) 588-2637 Director - Camp Buckeye Len_Martin@ucg.org P.O. Box 337 Delaware, OH 43015-0337

Camp Buckeye 2016 – Information/Packing List Location: Camp Luz, 152 Kidron Road, Orrville, OH 44667 Approximately 10 miles East of Wooster, Ohio. Dates: Sunday, July 31 to Wednesday, August 3 Ages: Campers should be 6-12 years of age. Fees: Camper - $100 - ($90 for each additional child in the same family) Teen Staff (14-19) - $65; Adult Staff (20+) - $35 Activities: Christian living class, archery, arts & crafts, bible skits, canoeing, court games, fishing,

field games, indoor games, swimming, "the way", Luz-ball, campfire w/ kettle corn & sing-a-long. Application Deadline:

Applications must be postmarked by June 1, 2016. Any applications after this date, add a late fee of $20. The cut-off date for ALL applications is June 30, 2016.

Changes – After submitting this form, please call or email to inform us of any changes or cancellations. Items to bring:

Clothes for each day Flashlight Swimsuit & sunscreen Insect repellant Sneakers Toothpaste/toothbrush Hat for sun, poncho for rain Soap, shampoo, deodorant Sleeping bag (or sheets/blanket) Hair brush/comb Pillow New white T-shirt (for painting / tie-dyeing) 2-3 towels & washcloth Old shirt or “smock” (to wear during arts/crafts) Plastic bag for wet clothes Flip flops or aqua socks (optional) 1 bottle of juice (turn in at Check-in) Water: Minimum of 6 bottles (turn in at Check-in)

Do NOT Bring: Radio/iPod/CD/MP3 players, electronic devices, electronic games, cell phones, knives,

firearms, fireworks, etc.

Arrival – Please follow instructions from the Parking Attendants, who will direct you where to park.

Campers should arrive between 3:00-4:00pm. ( Staff should arrive at Noon )

Arrival Schedule: (Sunday, July 31, 2016)

Noon - 1:00 PM Staff Arrives and registers 1:00 PM - 2:00 PM Staff Meeting and Orientation 3:00 PM - 4:00 PM Campers arrive and register 4:30 PM - 5:00 PM Camper Orientation

(NOTE: Staff should bring a sack lunch for Sunday since the kitchen will not yet be functioning)

Departure – Please follow instructions from the Parking Attendants, who will direct you where to park.

Please pick up your camper(s) at 6:00pm on Wednesday, however parents are encouraged to arrive in time to attend the Closing Ceremony from 5:00-6:00pm.

Departure Schedule: (Wednesday, August 3, 2016)

4:00 PM Dinner 5:00 PM Closing Ceremony (Parents encouraged to attend) 6:00 PM Campers Depart

Special Notes for Parents Health exams for preteen camps are not required, so campers and staff are not required to submit health

examination forms. We do require the first four pages of the Health History Form and we recommend that parents have their children examined by a medical practitioner at least every three years. When you choose to have one done, sending in a copy of you or your child’s health exam with your camp application is helpful to the first aid/nursing staff at camp.

At the end of camp if someone other than you (parent) is picking up your child, the parent must include an updated and signed Transportation & Sign In/Out Form to registration.

Parents will need to judge their children’s maturity in preparing for camp. At a bare minimum, campers should be able to tie his/her own shoes, walk in line, listen to and follow instructions, and use the restroom without adult assistance.

Prior to camp, parents are asked to discuss the following with their children: - Come to camp with a positive mental attitude! Be ready to jump into activities wholeheartedly,

participate in everything, and do it all in an attitude of unity and teamwork, always encouraging and not complaining.

- Work hard at developing friendships and getting along with everyone. Meanness, name-calling, fighting, put downs, are unacceptable and will not be tolerated.

- Be responsive and respectful to the counselors and other staff members. - Practical jokes are prohibited at camp. While they appear to be fun at the start, past experience

shows that they quickly escalate and do damage to people and/or property.

Discipline policy: - Our discipline philosophy is based upon a firm but fair adherence to four policies: those coming to

camp must respect authority, respect others, respect the property/facility, and respect self. - Counselors will strive to head off any discipline problems by positive teaching. - For minor infractions (meaning actions that do not affect the attitude, health or safety of the

camper or others) we will administer punishments such as extra cleanup duty, missing all or part of an activity, sitting or walking with the counselor, a writing assignment, etc.

- For major infractions (meaning actions that cause dissension, adversely affect the attitude, health or safety of the camper or others) the counselor will confer with the Camp Director and/or another ministerial staff member who will arrange appropriate disciplinary measures. This will likely include calling the parents for their advice and input. In rare, urgent circumstances a child may be expelled from the camp and parents will be expected to come and get their child immediately. (Note: corporal punishment {spanking} will not be utilized as a form of discipline at camp.) If you have any questions regarding the discipline policy, please feel free to contact the camp director.

If you are having financial difficulty, please check with your pastor before deciding that your child cannot attend. We want every eligible child who wishes to attend, to be given that opportunity and so do others in your congregation who may be able to help. We will strive to make attendance possible for all the kids who desire to come.

Staff Application Formfor Preteen Camp ____________

a United Youth Camps Sponsored by: United Church of God, IA

See attached documents or http://uyc.ucg.org for details

Attach

Recent Photo

Here

Note: Application cannot

be processed without a recent photo

---------------------------------------------------------------

Date of Photo:

GENERAL INSTRUCTIONS: Fill Out the Form(s) Completely. Some fields will automatically copy to other places in

the document. Include Your Payment. Make checks payable to the fund instructed online. Be On Time. Mail to the address specified on the website by the deadline, otherwise late

fees apply. Other Forms: Please review the website and submit ALL additional forms in order for

your application to be complete. PERSONAL INFORMATION Tracking Box

(for office use only) Date Received: Amount Paid: Volunteer Appl Sup Rec’d? Health History/Exam Form Rec’d? Participation Agreement Rec’d? Transportation Form Rec’d? Ministerial Evaluation Rec’d? Acceptance Letter Sent?

Applicant's Last Name (print): First Middle

Last grade completed before camp: Sex M F Age by 1st day of camp:

Address:

City: State: Zip:

Birth Date: / / E-Mail:

Home Phone number: ( ) Mobile Phone: ( ) Do you attend UCG services regularly? Yes No

If no, other church? Congregation: Pastor's name:

Adult T-shirt Size S M L XL XXL 3XL 4XL Swimming proficiency: Can't swim Beginner Intermediate Skilled

Are you current in Lifeguard, First Aid, CPR, etc? Yes No If yes, state certification:

Have you served as staff at United Youth Camps before? Yes No If yes, list most recent camp/year.

List all United Camp(s) you’re applying for this year in preference order:

POSITION(S) APPLYING FOR (Rate all the areas you are interested in staffing listed below or fill in from the camp’s information sheet, with #1 being your first choice.)

_____ Where ever you need me _____ Indoor Games _____ Photography / Videography

_____ Arts & Crafts _____ Kitchen / Food _____ Water / Swimming / Lifeguard

_____ Assistant Counselor _____ Maintenance / Cleaning / Laundry _____ Teaching Christian Living

_____ Counselor _____ Music / Song / Dance _____ Team Building

_____ Field / Outside Games _____ Nature Walk / Hike _____ Other - Specify: _________________

_____ First Aid / Infirmary _____ Outreach / Service Project _____ Other - Specify: _________________

AGREEMENT AND RELEASES Compliance with Rules: All United Camps maintain a high standard of conduct and dress, based on God’s laws, which is further stated in the Code of Honor. These standards and rules include, but are not limited to: No possession or use of alcohol, tobacco or illegal drugs; no sexual misconduct, theft, smoking, disorderly conduct, profanity, destruction of property or refusal to cooperate fully with the camp staff. Jewelry for body piercings (other than earrings for girls), short shorts, midriffs, halter-tops or wearing revealing or other inappropriate apparel (or lack thereof) will not be allowed. Hair should not be an unnatural color, and hair length should be appropriate (short for boys, longer for girls). Pets, personal sports equipment and staff use of private vehicles are not allowed at camp, except as noted in the acceptance package. Firearms or other weapons (including pocketknives) may not be brought without the written permission of the camp director. Under certain circumstances I am aware that a search of my belongings or living quarters may be made in my presence by camp staff. Staffwho do not comply with the camp’s rules and standards, or whose conduct or attitude undermines the positive environment and objectives of the camp, or have made any false, misleading or incomplete statement in this application or the Health History and Examination Form, are subject to being dismissed. If the staff is dismissed, he/she will be sent home at his or her expense. Photo Release: By my/our signature(s) below, I/we also hereby give consent and permission to the nonexclusive, noncommercial reproduction, publication or use by United Church of God, an International Association (“Church”) or anyone authorized by them, of any pictures or photographs (still, video or motion, individual or group), taken of the applicant at United Youth Camp or its related activities (including travel) or, if taken during any other Church-related activities, together with any caption or descriptive material, including the individual/staff’s name, without compensation to the undersigned. Said picture(s) may be used without limitation, on Church Web site(s), in Church publications, in “Festival” or other videos or promotions created by the Church, in Church-sponsored advertising, or in any television program or broadcast approved by the Church. General release: In consideration of the applicant being allowed to attend the camp, I/we hereby release, indemnify, save and hold harmless and covenant not to sue the United Church of God, an International Association, its officers, Council of Elders, agents, employees, volunteers and helpers and any other related entity (hereinafter collectively called the “Church”) from all actions, claims, demands or suits which are based upon, or result from injuries sustained by the applicant arising out of, or in the course of, said applicant’s participation or attendance at the camp. This release, however, shall not apply to claims covered by the Church’s liability insurance, but is applicable to claims not covered by that insurance. It is strongly recommended that you have your own medical insurance protection since participants are involved in activities at their own risk.

Parent(s) of Minors: Activities of the camp are described in the United Youth Camps annual brochure. I/we have read the brochure, are aware of the activities offered and hereby give permission for (applicant’s name)__________________________________ to attend camp, to be transported in camp-designated vehicles for any off-site activities and to participate in all the activities (unless otherwise noted on the Health History Examination Form and in the space on the preceding page). Permission is hereby given to search staffbelongings or living quarters with him/her present when health, well-being or safety of the staff or others require it, or where there has been an accusation or some evidence of his/her possession or use of forbidden materials or substances. I/we understand that if he/she violates camp rules or standards or endangers the safety or well-being of the camp, campers or other staff or otherwise fails to comply with the foregoing requirements to which he/she has agreed, that he/she can be sent home at the camp director’s request, which, I/we agree, will be at my/our expense. I/we understand there is no reimbursement of fees after 30 days before camp starts. Before that time, a processing fee of $40 will be withheld from the refund. I/we believe my/our son/daughter is in good health and can participate in strenuous activities and the usual routine associated with camp life. I/we verify and concur that the information supplied in this application and on the Health History and Examination Form is true and complete. Emergency Contact Information: Name:_________________________________ Relationship to Staff: __________________________ Home:___________________________________ Cell:___________________________________ Work: ______________________________________

If selected as a staff member, what can you contribute to camp?

SIGNATURES I have read, fully understand and agree to the foregoing, including rule compliance, photo and general release statements above. X Date Applicant’s Signature X Date X Date Father’s Signature (if Applicant is a minor) Mother’s Signature (if Applicant is a minor)

Preteen United Youth Camps Health History Form Page 1 of 4HH2013

Name Staff/Camper Dorm

Year

For Camp Use (Circle one) For Camp Use For Camp Use

Health History Form for Preteen United Youth Camps

Sponsored by: United Church of God, an International Association

This form must be completed (all 4 pages) by each person attending camp, or in the case of minors, by their parents or guardians. PLEASE PRINT.

PERSONAL INFORMATION

Applicant's Name: Sex: ○ Male ○ Female Birth Date: / / . First Middle Last

Address: Phone: ( ) Street Address City State Zip

Last Four Digits of Social Security Number of Participant: XXX – XX –

Parent/Guardian or Emergency Contact: Relationship:

Telephone: ( ) ( ) ( )

Home Work Other

Second Parent/Guardian/Emergency Contact: Relationship:

Telephone: ( ) ( ) ( ) Home Work Other

INSURANCE INFORMATION Please furnish the following medical and insurance coverage information:

Insurance Company: Policy or Group #

Social Security Number of Policyholder or Insurance ID Number: Policyholder Date of Birth:

Insurance Phone # ( ) Address:

Family Physician: Phone: ( )

Address:

Family Dentist/Orthodontist: Phone: ( )

Address:

MEDICAL HISTORY

Many activities such as sports and challenge courses require participating in physical exercises that are physically demanding. Do you have health problems or disabilities that might hinder you from participating fully in camp activities? ○ Yes ○ No

If yes, please describe in detail (attach note if necessary):

Preteen United Youth Camps Health History Form Page 2 of 4HH2013

Do you have any severe allergies (including food allergies) or any other condition or limitation that could affect your camp experience? ○ Yes ○ No If yes, please explain (attach note if necessary):

Are you allergic or sensitive to any medicines or other substances? ○ Yes ○ No If yes, please list and describe the reaction and its management:

Medications Being Taken

Are you taking any medications (including over-the-counter or other nonprescription drugs) routinely? ○ Yes ○ No

If yes, please list all medications (including over-the-counter or other nonprescription drugs) taken routinely. Be sure to bring your medication with you in the original packaging that will identify the doctor, the dosage and the frequency of administration:

Medication Dosage Frequency Reason for Taking

Health History – Explain any “yes” answers below

Has/does the participant: YES NO YES NO 1. Had any recent injury, illness or infectious

disease? .............................................................. □ □ 2. Have a chronic or recurring illness/condition?....... □ □ 3. Have frequent headaches? ................................... □ □ 4. Wear glasses, contacts or protective eye wear? ... □ □

5. Ever had frequent ear infections? ......................... □ □ 6. Ever passed out during or after exercise?............. □ □ 7. Ever been dizzy during or after exercise? ............. □ □ 8. Ever had seizures?................................................ □ □ 9. Ever had chest pain during or after exercise? ....... □ □ 10. Ever had high blood pressure? ............................. □ □

11. Ever been diagnosed with a heart murmur? ......... □ □

12. Ever had back problems?...................................... □ □

13. Have an orthodontic appliance being brought to camp?.............................................................. □ □

14. Have any skin problems (e.g., itching, rash, acne)?.................................................................. □ □

15. Have diabetes? ..................................................... □ □

16. Have asthma? ....................................................... □ □ 17. Had mononucleosis in the past 12 months? ......... □ □ 18. Have problems with sleepwalking? ....................... □ □ 19. Have a current history of bed-wetting? ................. □ □ 20. Have an eating disorder? ...................................... □ □

21. Ever had emotional or mental difficulties for which professional help was sought?............. □ □

If you checked “yes” to any of the above, please note the question number and explain.

Which of the following has the applicant had? (Check each one that applies) □ Measles □ Chicken Pox □ German Measles □ Mumps □ Rheumatic Fever □ Hepatitis A □ Hepatitis B □ Hepatitis C □ TB Test (Date: , Pos or Neg? )

Immunizations – Fill in the dates for any of the following immunizations applicant has had.

Immunization Date Last Received Immunization Date Last ReceivedDPT Mumps TD (tetanus/diphtheria) Rubella Tetanus Gamma Globulin (Hepatitis) Polio Chicken Pox German Measles Smallpox NOTE: A record of immunizations is for informational purposes. Immunizations are not a required prerequisite for acceptance to or attendance at camp. If a camper has not been immunized, however, and one of the above-named communicable or contagious diseases is found in camp, he or she will be subject to the regular quarantine or isolation procedures of the camp and of the community for children who are not immune.

Preteen United Youth Camps Health History Form Page 3 of 4HH2013

ADULT APPLICANT: I certify that to the best of my knowledge this health history is correct and complete, that I am in good health and able to participate in this event/assignment. Adult applicant signature Date

PARENT/GUARDIAN AUTHORIZATION: This health history is correct and complete as far as I know and the person herein described has permission to engage in all camp activities except as noted. I understand that if any statement in this Health History is false, misleading or incorrect, or the Church is unable, in its sole judgment, to properly care for or protect my child (due to his/her medical condition), he or she may be sent home at my expense. Parent signature Printed Name Date

PARENTAL NOTIFICATION POLICY: United Youth Camps policy is that parents will be contacted 1) anytime the nurse or a physician deems necessary; 2) anytime a camper is taken to see a physician, dentist or emergency personnel for an accident or illness; 3) when an illness lasts longer than 24 hours.

IMPORTANT – These boxes must be completed for attendance

Permission to Provide Necessary Treatment or Emergency Care: I hereby give permission to the available medical personnel at the camp to administer prescribed medications and provide routine health care, including over-the-counter medications, to my child as deemed necessary by the UYC medical staff. In the event of an accident/illness, I consent to the administration of emergency on-site first aid by trained personnel. If I cannot be reached in an emergency, I hereby give permission to the camp medical personnel to secure and administer treatment, including hospitalization, for the person named above. This authorization includes consent to any medical, emergency dental, surgical, chiropractic or hospital diagnosis, treatment or care to be rendered to or for me/or my child under the general or specific supervision of a qualified physician, surgeon, chiropractor or dentist. It also includes permission to release any records necessary for supervision, treatment, referral, billing or insurance purposes and to provide or arrange necessary related transportation. I understand and agree that the foregoing will be at my expense. This consent shall terminate without further notice on the date when a minor reaches 18 years of age. This completed form may be photocopied for trips out of camp.

Parent/guardian (or adult camper/staff) signature Printed Name Date

If medication for life-threatening conditions is brought to camp (epi pen, inhaler, etc.) I hereby request that said medication remain with: □ UYC Personnel □ My Child (Please check one.)

I understand that accommodating some medical conditions or disabilities may not be ideal and may differ depending on the activity. Therefore, if I am accepted, I agree to abide by any restrictions which may be placed on my camp activities that the camp staff feels are necessary for my comfort or safety or that of my fellow campers or staff. Camper/Staff signature Date

Special note about medication: Please note that if your camper will be bringing ANY medications to camp, including all prescription, over-the-counter and herbal remedies, the following rules will need to be followed: 1) All medications must be in their original packages. i.e. prescriptions in the prescription bottle, Tylenol in the Tylenol bottle, herbs in

the bottle that they were originally bought in. 2) All medications must be accompanied by written and signed instructions for administration (the prescription on the bottle will be

fine unless doses or times have changed). 3) Any nonprescription bottles must have the camper’s name written on them (prescription bottles must be for that camper).

PLEASE help us to take good care of the precious and wonderful campers that you have entrusted to us! – UYC Medical Staff

Preteen United Youth Camps Health History Form Page 4 of 4HH2013

INSURANCE COVERAGE AND RELEASE PAGE

Personal Medical Insurance The United Church of God is grateful to those who freely give of their time and expertise to assist in the operation of United Youth Camps (UYC). While we place a significant emphasis on safety at UYC for both staff and campers, accidents may happen and people may get injured. For this reason, we strongly recommend that you carry adequate personal medical insurance. We realize that it is not always affordable. However, paying actual hospital and doctor expenses can easily cost far more. As we review your application, this is an important factor in determining those most suited to serve at UYC.

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Supplemental Accident Insurance We realize that your personal insurance may require you to pay a deductible and co-payments, and possibly other costs. In an effort to help reduce the cost to you personally, the Church has been able to acquire supplemental accident medical coverage for a nominal cost. Though the Church is unable to provide financial assistance beyond what is offered through this insurance, we are happy to include all campers as well as staff volunteers in this coverage, particularly since they are not covered by Workers’ Compensation. The extent (amount and period) of accident coverage may vary from year to year. If you are accepted as a camper or approved to serve as a UYC staff member, a copy of the coverage will be supplied upon request.

*************************** Release and Waiver

I have read, fully understand, and agree to comply with all the rules and standards of this preteen camp and its staff. I understand and agree with its implications and the stated consequences. I also affirm that the information given in this application is true and complete and that I (or my child) am in good health and able to participate in the expected activities and routine for this preteen camp. In consideration of being allowed to participate, I hereby release, indemnify, save and hold harmless and covenant not to sue the United Church of God, an International Association, its officers, Council of Elders, agents, employees, volunteers and helpers and any other related entity (hereinafter collectively called the “Church”) from all actions, claims, demands or suits which are based upon, or result from a medical condition or injuries sustained, arising out of, or in the course of, participation or attendance at camp. This release, however, shall not apply to claims covered by the Church’s liability insurance (e.g. for its negligence) , but is applicable to claims not covered by that insurance. It is strongly recommended that you have your own medical insurance protection since participants are involved in activities at their own risk.

Signature Date Signed Print Name_

Parents’ Signature(s) also Required for Minors: I/we have read, fully understand and agree to the foregoing statements.

X Date X Date

Father Mother

A health examination for preteen camp is not required or mandatory, but it is recommended at least once every three years.

Official UYC Camp Website Sponsored by United Church of God, an International Association uyc.ucg.org Producers of Beyond Today TV and the Good News magazine

UYCTransportationandSignIn/OutForm Dear Parents, Campers and Staff, We are excited to see you at camp soon! In order to ensure the safe, orderly and authorized arrival and departure of all campers and staff to and from camp, we are asking that campers, parents and staff fill out and sign the information and authorization form below, and send it back with your application no later than the due date. At each camp’s discretion, this form can additionally be used for signing staff and campers in and out of the facility. ----------------------------------------------------------------------------------------------------------------------------------------------------------------

Arrival & Departure Authorization and Information Form Name of Camper or Staff: Last Name First Name

Arrival Date I will drive myself. I will be brought to camp by: Driver’s name: (please print)

Departure Date I will drive myself. I will be picked up from camp by: Driver’s name (please print) If there is any individual who under no circumstances would be allowed to pick up my child, please list that person(s) here:

I have fully read, understood and intend to comply with the procedures and rules listed on this and cover form. To the best of my knowledge the above information is complete and accurate. I (if parent of a minor participant) also authorize the above listed person(s) to transport my child to and/or from camp, and to register and/or sign-out him/her as needed and required. Signature of Parent or Adult Staff Member Signature of Minor Staff Member Date ----------------------------------------------------------------------------------------------------------------------------------------------------------------

Sign In and Out (At Camp)

Sign In Date / /

Time : am/pm Signature of Staff Member or Authorized Driver

Sign Out Date / /

Time : am/pm Signature of Staff Member or Authorized Driver

( This page intentionally left blank to assist when duplex printing )

Civil Record (lawsuits) Have you ever had a lawsuit filed or civil judgment entered against you or is there a pending complaint against you Date(s) of suit(s) concerning intentional injury against others, your treatment of minors or any other unchristian behavior? Yes No Location(s) of case(s) Case number(s) Is any such civil case currently If a judgment was entered against you, state its requirements. pending against you or on appeal? Yes No

Revised 2-16-2006

Criminal Record/Child Abuse Have you ever been convicted of child abuse, child molestation, child neglect, Date(s) of conviction(s) sexual assault, rape or any other sex crimes, drug crimes, violent crimes or any felonies? Yes No Have you ever committed or been charged with committing child abuse or any of the If yes, where and when? other offenses set forth above? Yes No

Is there any criminal case or accusation involving the foregoing abuse or If yes, please describe the nature of the case or accusation. other offenses currently pending against you or on appeal? Yes No If convicted, penalties imposed

United Church of God an International Association

Youth Program Volunteer Application Supplement Human Resources

Name Address City State Zip Phone Number Do you attend UCG services regularly? Name of local church pastor ( ) Yes No

Which congregation do you attend? How long have you attended? Are you a baptized member of the Church of God? If baptized, date of baptism Yes No

This supplement is required for youth program volunteers, including camp workers, of the United Church of God (herein “Church”) whose current or desired position includes, or might include, working with, or in close proximity to, minors.

Character Traits What character traits and abilities do you have that qualify you to work with youth in athletic programs and learning situations? Please list.

References

List each Church area you have attended and each Pastor you have had during the past ten years Name of Present Employer Street Address City State Zip Immediate supervisor Phone Number Length of time employed ( ) Please provide two references, people not related to you, that we may contact. These may include church members. Name: Email Address: Phone: ( ) Name: Email Address: Phone: ( )

Sexual Misconduct Policy I have read the Sexual Misconduct Policy and Youth Protection Guidelines of the United Church of God, an International Association. Yes No I have signed a copy of the “Participation Agreement for Youth Leaders”. Yes No It is on file with: my local pastor a Camp Director Provide the congregation name and pastor’s name or UYC Camp Director’s name:

Job Functions The essential job functions of a worker with youth programs may include a requirement to perform strenuous physical activities and may require skills in competitive sports which demand endurance and dexterity. Are you capable of performing those functions? Yes Yes No If reasonable accommodation is needed, how would you perform those tasks and with what accommodation(s)? with reasonable accommodation

Character Traits (continued) What character traits and abilities do you have that qualify you to work with youth in athletic programs and learning situations? Please list.

Approval: The applicant has been Comments (optional) Approved Denied

Approved by: X Date

Experience (This section for new applicants only)

Please provide a brief history of your experience working with youth programs of the Church, local schools and other organizations. (Use additional sheet if necessary). Date Type of experience Program director’s name Address City State Zip Phone number

( )

Date Type of experience Program director’s name Address City State Zip Phone number ( ) Date Type of experience Program director’s name Address City State Zip Phone number

( ) Date Type of experience Program director’s name Address City State Zip Phone number

( )

Automobile Information Do you have a driver’s license? Yes No State License number Do you have an automobile you Yes No Make of car Year can use for the youth program? Do you have automobile insurance? Yes No Insurance company Policy number Liability limits per person Liability limits per accident Property damage limits Are you under an “assigned risk” policy? Yes No If yes, please explain the reason(s)

Applicant’s signature Date

Applicant’s Signature: I authorize the Church to make inquiries to verify the statements contained in this Supplement. I release the Church and any person, company or institution that provides the Church with information concerning my background, from any and all liability or claims that may result from the inquiries, use or disclosure of such information.

X

Personal Insurance Do you have Personal Medical Insurance? Yes No Company Policy Number

PARTICIPATION AGREEMENT FOR YOUTH LEADERS

In May 2004 The Council of Elders of the United Church of God, an International

Association (“Church”) formally adopted a “Sexual Misconduct Policy and Child

Protection Guidelines” (“Guidelines”). Said Guidelines were amended on February 24,

2014. In order to be allowed to participate or be a leader in Church programs, activities

for children or youth or otherwise caring for those minors under the auspices of the

Church, you must read and agree to abide by those Guidelines. Please indicate below

whether or not you are willing to participate in Church sponsored youth programs, etc., in

accordance with said Guidelines:

I Agree. I have received, read, understand, and hereby agree to abide by and to

comply with the procedures and policies laid out in said Guidelines, as amended, and to

faithfully follow those requirements.

I acknowledge that I must obtain prior written permission from the Church’s Council of

Elders, or those they designate, before implementing any exceptions to these Guidelines

(except in emergency situations, in which case I am allowed to take the most prudent or

common sense course of action necessary to supervise and protect Church youth).

I understand that under the Guidelines my continuing participation or leadership in the

Church’s programs or activities for children or youth is contingent on my confirmation

that I have no past history of committing child abuse. Consequently, I hereby confirm

that I have never committed, nor have I ever been convicted of, child abuse, child

molestation, child neglect or sexual assault, rape or any other sex crime or violent crime

against a minor. I also give the Church permission to run a background check on me to

verify the above, which could include accessing and reviewing my criminal history,

should the Church desire to do so in the future.

Dated: _______________________ Signed: _______________________________

Print Name: _______________________________

I Decline. At this time I do not wish to participate or be a leader in the Church’s

youth programs or activities under the aforesaid Guidelines. If I am currently involved as

a participant, youth leader or in the care of minors under the auspices of the Church I

hereby resign from that position(s).

Dated: _______________________ Signed: _______________________________

Print Name: _______________________________