First name: Last name: Gender: Male Female

Phone Number: Email Address:

Social Security Number: -- (Necessary for background check) Birthday:

Address: City: State: Zip:

Emergency Contact:

Relationship to you: Phone # H: Cell:

Persons who can respond to your qualifications as a camp employee. Please fill out the following information.

1) Christian Worker (Youth Pastor/Director):

Home Phone: Cell:

Address: City: State: Zip:

How long have you known this accquaintance?

2) Current or Past Employer (if applicable):

Home Phone: Cell:

Address: City: State: Zip:

How long have you known this accquaintance?

3) Other non-family reference:

Home Phone: Cell:

Address: City: State: Zip:

How long have you known this accquaintance?

I give Riverview permission to contact the above references

Would you be interested in helping lead worship if asked? Yes No

What dates are you available to work? to

What do you hope to give and receive from a Summer Staff experience?

Have you ever worked at Riverview? Yes No When?

Please briefly share your testimony.

What do you see are your biggest strengths and weaknesses?

Have you ever been convicted of a crime? Yes No (Please note a "Yes" answer will not necessarily disqualify you)

Will you work overtime if asked? Yes No

The following job positions are available: please prioritize them using 1 as your first choice, 2 as your second choice, etc. Starred job positions may require lifeguard certification.

Guest services*

Landscaping*

Program*

Kitchen

Rugged Faith (Outdoors ministry)

Video editing/photography

By checking this box, you agree that all the above information is correct as far as you know, and you agree to let us conduct a background check before hiring you.

I agree.