What are you applying for?

Camp Counselor

Sr High Camp Counselor - must be 21 or older

Jr High Camp Counselor - must be 18 or older

Kids Camp Counselor - must be 18 or older

Counselor in Training (CIT)

Kids Camp Counselor in Training - must be 16 or older

Jr High Counselor in Training - must 16 or older

Background Check Information

Pursuant to KRS 17.160, a request if made for any record of conviction of a crime in KRS Chapter

531, 510, 218A, and 189A by the person identified herein.

This information shall be released to:

Kentucky Church of God Ministries, 2494 Colby Road, Winchester, Kentucky 40391

Date of Birth

Drivers's License #:

State where Driver's License Issued:

City and State where you were born

Have you had any altercations with law enforcement in the past three years that you were convicted of? (Including traffic tickets)

Have you had a job change in the last 3 years? If yes, please list previous job:

Please list any previous addresses in the last 10 years

Discrimination Statement:

“The information on this form is required for identification purposes for background screening processing only and is in no manner used as qualifications for credentialing. The General Assembly of the Church of God, and the Credentials Committee do not discriminate on the basis of sex, race, religion, age (40 and over), handicap, or national origin.”

I have read and agree to the terms above.

Confidentiality Statement:

“All information gathered in the process of credentialing will be maintained in secured, confidential files and will be made available only to authorized credentials personnel at Kentucky Church of God Ministries and, in the event of transferring credentials, to the transferring state’s Church of God credentials office. This confidentiality may be breached only with the consent of the applicant, or when there appears to be clear and imminent danger to the applicant, others, or society.”

I have read and agree to the terms above.

Authorization

Authorization: During the application process at Kentucky Church of God Ministries, I hereby authorize Kentucky Church of God Ministries, on behalf of The General Assembly of the Church of God, to procure a consumer report which I understand may include information regarding my credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. This report may be compiled with information from credit bureaus, courts record repositories, departments of motor vehicles, past or present employers and educational institutions, governmental occupational licensing or registration entities, business or personal references, and any other source required to verify information that I have voluntarily supplied. I understand that I may request in writing a complete and accurate disclosure of the nature and scope of the background verification; to the extent such investigation includes information bearing on my character, general reputation, personal characteristics or mode of living.

I, the undersigned, agree to the terms above.