Name

First Name

Last Name

Email Address

PRELIMINARY INFORMATION

Age

Birth Date

YYYY

Gender

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone

(###)

###

####

Emergency Contact Name

Contact's Phone Number

(###)

###

####

Are you engaged?

Are you married?

Do you have any tattoos?

Do you have any body piercings (besides earrings)?

Health Insurance

Policy Number

Current or most recent place of employment

What school are you attending (or did you last attend)?

Present Year of School

Major and Minor

Extra Curricular Involvement

School's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Dorm and Room #

Box #

Home Church

Church Location

Pastor's Name

SUMMER INFORMATION

Please check any of the following skills in which you have training/experience

Current Lifeguard Certification

Paramedic

CWP

Do you have any musical skills? Please list instruments and vocal abilities

Do you have any food restrictions or allergies? Please list any.

REFERENCES

Please list the names and contact information for two adults, not related to you, who we can contact on your behalf

Pastor/Youth Pastor

Reference 1: Email

Reference 1: Phone

(###)

###

####

Teacher/Christian Worker/Employer

Reference 2: Email

Reference 2: Phone

(###)

###

####

PERSONAL GROWTH

What Christian services were you involved in this past year?

What has God been doing in your life since working at PBC?

What have you learned from your personal devotions in the past two or three weeks?

By signing below, I authorize all references to disclose any information that they may have regarding my character and fitness for working with youth at PBC. I understand that as a part of the application process, I consent to a criminal background check. I agree with PBC's Statement of Faith.

You can access the Statement of Faith here. Electronic Signatures. This agreement, agreements ancillary to this agreement, and related documents entered into in connection with this agreement are signed when a party’s signature is delivered by facsimile, e-mail, or other electronic medium. These signatures must be treated in all respects as having the same force and effect as original signatures.

Date Signed

YYYY

Thank you! We will send you a confirmation email soon.

Returning Staff Application