Upstate District Teen Camps

Counselor Application - CONFIDENTIAL

2018 Camp Program Directors:
Camp 789: Carey Dunlop (260)-224-7770 or cdunlop@findcommunity.net
4045 E. Henrietta Rd. Henrietta, NY 14467
Senior High: Doug Parks (607)206-2395 or Pouglas60@gmail.com)
800 Park Ave. Binghamton, NY 13903
Requirements for a counselor are as follows:
Age 21+ (applicants ages 18-20 please contact Camp Director prior to submitting application)
Actively involved in your local church
Able to fully participate in the camp schedule
Display a lifestyle consistent with the beliefs & practices of the Nazarene Church
Have a love for students and an expectancy that God will do great things in their lives (and yours)
during the week of camp!
Please check which camp week(s) you would like to serve:
Camp 789 (grades 7-9) July 16th - 21st, 2018
Senior High (grades 10-12+) July 30th - August 4th, 2018

Applicant information

Full Name: Gender: M / F

Mailing Address: City/State/ZIP:
Home Phone: Cell Phone:
DOB (M/D/YY): ___/____/_____ Church:________________________________________
Social Security #: Email:
Medical Allergies/lssues of concern:

Occupation:
Emergency Contact
Name: Phone: Relationship:

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Personal Information:
Have you personally accepted Jesus Christ as your Lord and Savior, and are you committed to
having the character of Jesus displayed in your life?

Briefly describe your relationship with God right now.

Why have you chosen to apply to be a teen camp counselor?

Have you, at any time, been accused (rightly or wrongly) of sexual abuse, maltreatment, or
neglect? If “Yes” please explain:

Have you ever been accused or convicted of possession/sales of controlled substances or driving
under the influence of alcohol or drugs? If “Yes” please explain:

Have you ever been arrested or convicted of any criminal act (aside from a traffic violation)?
If “Yes” please explain:

Have you been a victim of sexual or physical abuse?

If “yes” please explain:

What strengths do you bring to the leadership team at Upstate Teen Camp?

What do you perceive are your weaknesses inregards to being teen counselor?

Is there anything not already discussed, that you would like to share with the camp director?

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 References:
List three adults you've known for at least one year, who are not related to you, and have a definite
knowledge of your character and ability to work with students.
1. Pastor/Youth Pastor of the church you are presently involved in:
Name: Length of time known:
City/State: Work phone:
Home/Cell phone: Email:

2. Employer or fellow employee:

Name: Length of time known:
City/State: Work phone:
Home/Cell phone: Email:
What is your relationship to this person?__________________________________________

3. Friend:

Name: Length of time known:

City/State: Work phone:
Home/Cell phone: Email:
What is your relationship to this person?_______________________________________

Signature
By submitting this completed application, I am committing to be a camp counselor (if accepted) for
the dates I have selected on page 1. Additionally, I understand I will be responsible for the care and
safety of adolescents ranging in age from 12-15 or 15-18. I have completed this application to the
best of my knowledge, and have provided truthful information. I also give permission to the Upstate
NY District NYI Council and Camp Director(s) to contact my references and perform a criminal
background check in accordance with NYS Health Department regulations. I understand that all
information provided on this application is confidential and will only be used in reference to my
status as an Upstate NY District camp counselor/volunteer.

Signed/Date: ____________________________________________________
Applicants will be notified of their acceptance as a counselor by phone or email.

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