Camp Kahoka Staff Application


Camp Kahoka


Staff Application


Camp Kahoka
734 Ben Cartwright Lane
Mountain View AR 72560
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Applicant Agreement
I represent that I am the person who appears on the application above. I acknowledge and agree to the statements, terms and conditions above, as well as any applicable terms and conditions for this registration, and that by typing my name below and completing this registration form, I am electronically signing the document, which will have the same legal effect as the execution of the document by a written signature and shall be valid evidence of my intent and agreement to be bound.

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Registration inquiries:
Camp Coordinators
Tom & Stephanie Thompson
8321 Button Cove
Sherwood AR 72120
501-590-6444
stephanie@campkahoka.org
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Kid's Camp
Senior Camp
Retreat
Cabin Leader
Concessions
Crafts
Dean
Devotional Leader
Director
Evangelist
Fun-Time Director
Kitchen Staff/Cook
Nurse
Recreation Director
Secretary
Teacher
Worship Team
Other
HEALTH DATA
YES
NO

MEDICAL CONSENT:

IN THE CASE OF A MEDICAL EMERGENCY, I UNDERSTANDTHAT REASONABLE EFFORT WILL BE MADE TO CONTACT EMERGENCY PERSON(S) DESIGNATEDABOVE. IN THE EVENT THEY CANNOT BE REACHED, I GIVE PERMISSION TO CAMP KAHOKAADMINISTRATION AND PHYSICIAN SELECTED TO SECURE ANY AND ALL PROPER MEDICALTREATMENT FOR, TO ADMINISTER OTC OR PRESCRIPTION MEDICATIONS, TO HOSPITALIZE,ORDER INJECTION, ANESTHESIA, AND/OR SURGERY FOR ME. I UNDERSTAND THAT MYINSURANCE HAS THE PRIMARY RESPONSIBILITY OF PAYMENT SHOULD I NEED TREATMENT.CAMP KAHOKA INSURANCE IS SECONDARY.

PARENT OR GUARDIAN MUSTSIGN IF UNDER 18
SPIRITUAL & BACKGROUND DATA
SAVED
SANCTIFIED
BAPTIZED IN HOLY GHOST
BAPTIZED IN WATER
COGOP MEMBER
COGOP ATTENDEE

PERMISSON TO OBTAIN BACKGROUND CHECK 

I  HEREBY AUTHORIZE CAMPKAHOKA, THE CHURCH OF GOD OF PROPHECY, (CK/COGOP) AND/OR ITS AGENTS TO MAKEINVESTIGATION OF MY BACKGROUND, REFERENCES, CHARACTER, PAST EMPLOYMENT,CONSUMER REPORTS, EDUCATION, AND CRIMINAL HISTORY RECORD INFORMATION WHICH MAYBE IN ANY STATE OR LOCAL FILES, INCLUDING THOSE MAINTAINED BY BOTH PUBLIC ANDPRIVATE ORGANIZATIONS, AND ALL PUBLIC RECORDS, FOR THE PURPOSE OF CONFIRMINGTHE INFORMATION CONTAINED ON MY APPLICATION AND/OR OBTAINING OTHER INFORMATIONWHICH MAY BE MATERIAL TO MY QUALIFICATIONS FOR EMPLOYMENT. A TELEPHONEFACSIMILE (FAX), XEROGRAPHIC COPY OR ELECTRONIC COPY OF THIS CONSENT SHALL BECONSIDERED AS VALID AS THE ORIGINAL CONSENT.

 

I HEREBY CONSENT TOCK/COGOP’S VERIFICATION OF ALL THE INFORMATION I HAVE PROVIDED ON MYAPPLICATION FORM. I ALSO AGREE TO EXECUTE ANY ADDITIONAL WRITTEN AUTHORIZATIONNECESSARY FOR CK/COGOP TO OBTAIN ACCESS TO AND COPIES OF RECORDS PERTAINING TOTHIS INFORMATION. WITH REGARD TO THE FOREGOING DISCLOSURES, I HEREBY AGREE TORELEASE ANY PERSON, COMPANY, OR OTHER ENTITY FROM ANY AND ALL CAUSES OF ACTIONTHAT OTHERWISE MIGHT ARISE FROM SUPPLYING CK/COGOP WITH INFORMATION IT MAYREQUEST PURSUANT TO THIS RELEASE. I UNDERSTAND THAT ANY FALSE ANSWERS ORSTATEMENTS, OR MISREPRESENTATIONS BY OMISSION, MADE BY ME ON THIS APPLICATIONOR ANY RELATED DOCUMENT, WILL BE SUFFICIENT FOR REJECTION OF MY APPLICATION ORFOR MY IMMEDIATE DISCHARGE SHOULD SUCH FALSIFICATIONS OR MISREPRESENTATIONS BEDISCOVERED HEREAFTER.

COVID STATEMENT & WAIVER

CAMP KAHOKA HAS PUT IN PLACE PREVENTATIVE MEASURES TO REDUCE THESPREAD OF COVID-19; HOWEVER, CAMP KAHOKA CANNOT GUARANTEE THAT YOU OR YOURCHILD(REN) WILL NOT BECOME INFECTED WITH COVID 19. FURTHER, ATTENDING CAMPKAHOKA COULD INCREASE YOUR RISK OF CONTRACTING COVID-19.

BY SIGNING THIS AGREEMENT, I ACKNOWLEDGE THE CONTAGIOUS NATURE OFCOVID-19 AND VOLUNTARILY ASSUME THE RISK THAT MY CHILD(REN)/I MAY BE EXPOSED TOOR INFECTED BY COVID-19 BY ATTENDING CAMP KAHOKA AND THAT SUCH EXPOSURE ORINFECTION MAY RESULT IN PERSONAL INJURY, ILLNESS, PERMANENT DISABILITY, ANDDEATH. I UNDERSTAND THAT THE RISK OF BECOMING EXPOSED TO OR INFECTED BYCOVID-19 AT CAMP KAHOKA MAY RESULT FROM THE ACTIONS, OMISSIONS, OR NEGLIGENCEOF MYSELF AND OTHERS, INCLUDING, BUT NOT LIMITED TO, CAMP KAHOKA EMPLOYEES,VOLUNTEERS, AND PROGRAM PARTICIPANTS AND THEIR FAMILIES.

I UNDERSTAND THAT MY CHILD(REN)/ I MUST BE FREE FROM COVID-19SYMPTOMS, AND SHOULD SYMPTOMS DEVELOP WHILE IN THE CARE OF CAMP KAHOKA, MYCHILD(REN)/ I WILL BE SEPARATED FROM THE REST OF THE CAMP PARTICIPANTS/STAFF. IWILL BE CONTACTED, AND MY CHILD MUST BE PICKED UP WITHIN THREE HOURS OF MYBEING NOTIFIED. I FURTHER VOLUNTARILY AGREE THAT CAMP KAHOKA MAY MONITOR MYSELFOR MY CHILD(REN) FOR SYMPTOMS OF COVID-19 (INCLUDING, BUT NOT LIMITED TO, FEVEROF 100.4 DEGREES FAHRENHEIT OR HIGHER, SHORTNESS OF BREATH, CHILD, DRY COUGH,SORE THROAT, AND MUSCLE ACHES)

I WILL IMMEDIATELY NOTIFY CAMP MANAGEMENT IF I BECOME AWARE OF ANYPERSON WITH WHOM MY CHILD OR I HAVE HAD CONTACT EXHIBITS ANY SYMPTOMS OFCOVID-19, IS ADVISED TO SELF-ISOLATE, QUARANTINE, OR HAS TESTED POSITIVE FORCOVID-19.

I VOLUNTARILY AGREE TO ASSUME ALL OF THE FOREGOING RISKS ANDACCEPT SOLE RESPONSIBILITY FOR ANY INJURY TO MY CHILD(REN) OR MYSELF (INCLUDINGBUT NOT LIMITED TO, PERSONAL INJURY, DISABILITY, AND DEATH, ILLNESS, DAMAGE,LOSS, CLAIM, LIABILITY, OR EXPENSE, OF ANY KIND, THAT I MAY EXPERIENCE OR INCURIN CONNECTION WITH MY ATTENDANCE AT CAMP OR PARTICIPATION IN CAMP PROGRAMMING("CLAIMS”) ON MY BEHALF, I HEREBY RELEASE, COVENANT NOT TO SUE, DISCHARGE, ANDFOREVER HOLD HARMLESS CAMP KAHOKA, THE HEARTLAND REGION CHURCH OF GOD OFPROPHECY, ITS BOARD, DIRECTORS, OFFICERS, EMPLOYEES, AGENTS, CONTRACTORS AND AFFILIATESAS WELL AS THE RELEASE PARTIES AND REPRESENTATIVES OF AND FROM THE CLAIMS,INCLUDING ALL LIABILITIES, CLAIMS, ACTIONS, DAMAGES, COSTS OR EXPENSES OF ANYKIND ARISING OUT OF OR RELATING THERETO. I UNDERSTAND AND AGREE THAT THISRELEASE INCLUDES ANY CLAIMS BASED ON THE ACTIONS, OMISSIONS, OR NEGLIGENCE OFTHE CAMP, ITS EMPLOYEES, AGENTS, AND REPRESENTATIVES, WHETHER A COVID-19INFECTIONS OCCURS BEFORE, DURING OR AFTER PARTICIPATION IN ANY CAMP PROGRAM.

IN WITNESS WHEREOF EACHPARTY HERETO HAS EXECUTED THIS WAIVER BY ITS AUTHORIZED SIGNATORY AS OF THEDAY, MONTH, AND YEAR INDICATED BELOW, AND THE WAIVER BECOMES EFFECTIVE UPON THEDATE OF THE LAST SIGNATURE HERETO. PARENT OR GUARDIAN MUST SIGN IF UNDER 18.  
STATEMENT OF GOOD MORAL CHARACTER
 

AS A CANDIDATE TO SERVE AS VOLUNTEER IN THE CAMPING MINISTRIES OFTHE CHURCH OF GOD OF PROPHECY, I HEREBY ATTEST, UNDER PENALTY OF PERJURY, THATI AM OF GOOD MORAL CHARACTER, AND THAT I HAVE NOT BEEN FOUND GUILTY OF,REGARDLESS OF ADJUDICATION, OR ENTERED A PLEA OF NOLO CONTENDERE ORGUILTY TO, ANY CRIMIE IN MY COUNTRY OF ORIGIN, OR UNDER ANY SIMILAR STATUE OFIN THE UNITED STATES OF AMERICA. I ALSO ATTEST THAT I DO NOT HAVE A DELINQUENCYRECORD THAT IS SIMILAR TO ANY OF THESE OFFENSES RELATING TO:

1.        MURDER, MANSLAUGHTER, AGGRAVATED MANSLAUGHTEROF AN ELDERLY PERSON OR DISABLED ADULT, OR AGGRAVATED MANSLAUGHTER OF A CHILD,VEHICULAR HOMICIDE, OR KILLING OF AN UNBORN CHILD BY INJURY TO THE MOTHER.

2.        AGGRAVATED BATTERY OR AGGRAVATED ASSAULT, ORSIMPLE BATTERY OR ASSAULT OF A MINOR

3.        KIDNAPPING, FALSE IMPRISONMENT OR REMOVINGMINORS FROM THE STATE OR CONCEALING MINORS CONTRARY TO COURT ORDER.

4.        SEXUAL BATTERY

5.        PROSTITUTION

6.        LEWD AND LASCIVIOUS BEHAVIOR AND INDECENTEXPOSURE

7.        ARSON

8.        INCEST

9.        CHILD ABUSE, AGGRAVATED CHILD ABUSE, NEGLECTOF A CHILD, NEGLIGENT TREATMENT OF CHILDREN, CONTRIBUTING TO THE DELINQUENCY ORDEPENDENCY OF A CHILD, AND SEXUAL PERFORMANCE BY A CHILD.

10.     OBSCENE LITERATURE

11.     ADULT ABUSE, NEGLECT OR EXPLOITATION OF AGEDPERSONS OR DISABLED ADULTS

12.     DRUG ABUSE PREVENTION AND CONTROL, ONLY IF THEOFFENSE WAS A FELONY OR IF ANY OTHER PERSON INVOLVED IN THE OFFENSE WAS A MINOR

13.     FRAUDULENT SALE OF CONTROLLED SUBSTANCES, ONLYIF THE OFFENSE WAS A FELONY

14.     FORCIBLE FELONY

15.     ASSAULT, IF THE VICTIM OF THE OFFENSE WAS A MINOR

16.     BATTERY, IF THE VICTIM OF THE OFFENSE WAS AMINOR

17.     ABUSE, AGGRAVATED ABUSE, OR NEGLECT OF ANELDERLY PERSON OR DISABLED ADULT, LEWD OR LASCIVIOUS OFFENSES COMMITTED UPON ORIN THE PRESENCE OF ELDERLY PERSON , OR DISABLED ADULT AND EXPLOITATION OF AN ELDERLYPERSON OR DISABLED ADULT, IF THE OFFENSE WAS A FELONY

18.     THEFT, ROBBERY, AND RELATED CRIMES, IF THEOFFENSE IS A FELONY

I UNDERSTAND THAT I MUST ACKNOWLEDGE THE EXISTENCE OF ANY RECORDSRELATING TO THE FOREGOING LIST OF OFFENSES REGARDLESS OF WHETHER THOSE RECORDSHAVE BEEN SEALED OR EXPUNGED. I ALSO UNDERSTAND THAT I AM OBLIGATED TO NOTIFYTHE CAMP KAHOKA OFFICE OF ANY POSSIBLE DISQUALIFYING OFFENSES THAT MAY OCCURWHILE EMPLOYED/VOLUNTEERING IN A POSITION SUBJECT TO THE SCREENINGREQUIREMENTS.

I FURTHER ATTEST THAT I HAVE NOT BEEN JUDICIALLY DETERMINED TOHAVE COMMITTED ABUSE, NEGLECT, OR EXPLOITATION AGAINST A CHILD NOR HAS THEREBEEN A CONFIRMED REPORT OF ABUSE, NEGLECT OR EXPLOITATION WHICH HAS BEENUNCONTESTED OR UPHELD. I HAVE NOT COMMITTED AN ACT WHICH CONSTITUTED DOMESTICVIOLENCE.

I HEREBY RELEASE AND AGREE TO HOLD HARMLESS FROM LIABILITY ANYPERSON(S) OR ORGANIZATION(S) WHO IN GOOD FAITH, PROVIDES INFORMATION TOCOMPLETE A BACKGROUND INVESTIGATION. I ALSO AGREE TO RELEASE AND HOLD HARMLESSCAMP KAHOKA, THE CHURCH OF GOD OF PROPHECY, ITS BOARD, DIRECTORS, OFFICERS,EMPLOYEES, AGENTS, CONTRACTORS, AND AFFILIATES AS WELL AS RELEASE PARTIES ANDREPRESENTATIVES OF AND FROM ANY PRESENT OR FUTURE CLAIM OF ANY KIND RESULTINGFROM ANY ALLEGED LIABILITY FOR CONDUCTING A BACKGROUND INVESTIGATION WHICH MAYINCLUDE, BUT NOT LIMITED TO , CRIMINAL COURTS, STATE, AND COUNTY REPOSITORIESOF CRIMINAL RECORDS.

UNDER THE PENALTIES OFPERJURY, I DECLARE THAT I HAVE READ THE FOREGOING AND THE FACTS ALLECTED ARE TRUETO THE BEST OF MY KNOWLEDGE AND BELIEF.

APPLICANT'S STATEMENT & WAIVER 

I UNDERSTAND THAT THERE IS NO REMUNERATION FOR ANY WORK PROVIDED;THEREFORE, ALL ASSISTANCE IS CONSIDERED VOLUNTEER LABOR. MY APPLICATION ISCAREFULLY COMPLETED. I UNDERSTAND IT WILL BE PRAYERFULLY CONSIDERED BY CAMPDIRECTORS & CAMP COORDINATORS. IF SELECTED, I WILL READ AND ABIDE BY RULESOUTLINED IN THE POLICIES & PROCEDURES MANUAL. I GIVE MY PERMISSION OF CAMPKAHOKA ADMINISTRATION TO USE IMAGES AND RECORDINGS OF MY CHILD/WARD/MYSELF(INCLUDING SOCIAL MEDIA OR WEBSITE USE) WITHOUT FURTHER COMPENATATION.

ICERTIFY THAT ALL THE INFORMATION PROVIDED ON THIS APPLICATION IS ACCURATE TOTHE BEST OF MY KNOWLEDGE. I HAVE READ AND UNDERSTAND THE CAMP PROGRAM STATEMENTWHICH CONTAINS THE RULES AND REGULATIONS, AND ALSO UNDERSTAND THAT BY SIGNINGTHIS APPLICATION I AM AGREEING TO ABIDE BY THOSE RULES. I UNDERSTAND THATFAILURE TO DO SO COULD RESULT IN DISMISSAL FROM CAMP. I ALSO AGREE THAT THECHURCH OF GOD OF PROPHECY (LOCAL, REGIONAL, AND INTERNATIONAL OFFICES), AND ITSOFFICERS, SERVANTS, OR STAFF SHALL NOT BE HELD RESPONSIBLE FOR DAMAGES FOR ANYACCIDENT OR SICKNESS.


I ACKNOWLEDGE AND AGREE TO THE STATEMENTS,TERMS AND CONDITIONS ABOVE, AS WELL AS ANY APPLICABLE TERMS AND CONDITIONS FORTHIS REGISTRATION. I ACKNOWLEDGE THAT TYPING MY NAME BELOW AND COMPLETING THISREGISTRATION FORM, I AM ELECTRONICALLY SIGNING THE DOCUMENT, WHICH WILL HAVETHE SAME LEGAL EFFECT AS THE EXECUTION OF THE DOCUMENT BY A WRITTEN SIGNATUREAND SHALL BE VALID EVIDENCE OF MY INTENT AND AGREEMENT TO BE BOUND.