Date of Birth *

MM

DD

YYYY

Permanent Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Current Address

(If Different)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Certifications

Please mark the following that you have current certifications in:

Lifeguard

Lifeguard Trainer

CPR/AED

First Aid

CDL

Reference 1 Name *

First Name

Last Name

Reference 1 Phone

(###)

###

####

Reference 2 Name *

First Name

Last Name

Reference 2 Phone

(###)

###

####

Reference 3 Name *

First Name

Last Name

Reference 3 Phone

(###)

###

####

Staff Agreement *

Realizing the great responsibility and opportunity of working with children at Camp Ao-Wa-Kiya, I agree to: Sacrifice personal desires in the interest of the campers; cooperate with the director and other leaders under whom I serve; obey camp and staff regulations printed in the staff manual; endeavor to be a blessing to the campers with whom I work by helping to enrich their lives spiritually, physically, and mentally; and uphold the standards and doctrinal position of Camp Ao-Wa-kiya (a copy of the doctrinal statement may be obtained at ao-wa-kiya.org). I hereby release and agree to hold harmless from liability any person or organization, whether listed or not, who provides information or references about me to Camp Ao-Wa-Kiya. I waive any right I might have to inspect references provided on my behalf. I certify that I have neither been convicted of, nor am I the subject of pending charges, for any offence involving actual or attempted child abuse or sexual molestation in any jurisdiction.

I Agree