Name *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Gender *

Male

Female

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Contact Phone *

(###)

###

####

Check which dates you will be available: *

(check as many as possible)

Week 1: May 28-31 (Tuesday-Friday)

Week 2: June 3-6 (Monday-Thursday)

Week 3: June 10-13 (Monday-Thursday)

Week 4: June 17-20 (Monday-Thursday)

Week 5: June 24-27 (Monday-Thursday)

Check ministry opportunities that interest you: *

(check all that apply)

Food Service

Horseback Riding

Special Events (zipline, archery, canoeing, golf, etc.)

Crafts

Concessions

Nurse/First Aid

Games/Recreation

Praise and Worship

Photographer

Videographer

Other (please list below)

Have you accepted Jesus as Lord and Savior of your life? *

Yes

No

If yes, approximate date?

MM

DD

YYYY

Have you been baptized? *

Yes

No

Have you ever worked with children? *

If yes, please list what age group and in what setting below.

Yes

No

Have you ever been convicted of an offense involving a minor? *

If yes, please describe the conviction(s) below.

Yes

No

Are there any facts or circumstances, including those that are physical or mental health related involving you or your background that would question your ability to be entrusted with the supervision, guidance and/or care of children? *

If you prefer, you may discuss your answer in confidence with the children’s minister or you may explain below.

Yes

No

Do you have a current Oklahoma driver license?

Yes

No

Reference 1 Name *

First Name

Last Name

Reference 1 Phone *

(###)

###

####

Reference 2 Name *

First Name

Last Name

Reference 2 Phone *

(###)

###

####

Applicant's Statement *

The information I have given in this application is correct and complete to the best of my knowledge. I hereby grant Cornerstone Kids’ Ranch permission to do a background check on me. I hereby request any reporting agency Cornerstone Kids' Ranch should choose to release any information, which pertains to any record of convictions contained in its file maintained on me whether local, county, state, or national. I hereby release said departments from any and all liability resulting from such disclosure.

I have read and agree with the statement above.