2024 INTERN FORM
INTERN Program
THIS FORM IS FOR VOLUNTEERS
AND IS NOT AN APPLICATION FOR EMPLOYMENT

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Full Name *
Permanent Address *
City *
State *
Zip Code *
Cell Phone *
Date of Birth *
MM
/
DD
/
YYYY
Sex *
Drivers License # *
State issued *
Social Security # *
Email Address *
Health Insurance Carrier Name *
Group# *
Address
Policy# *
Explain any medical Conditions we should be aware of: *
Note any prescription medications currently used: *
Note Allergies: *
Date of last Tetanus:
MM
/
DD
/
YYYY
Emergency Contact *
Emergency contact phone# *
In an emergency, I hereby give permission to a licensed physician to hospitalize and secure proper treatment, anesthesia, and surgery for myself. In case of emergency return for medical reasons the undersigned will be responsible for covering any added expense. I realize that I participate at my own risk. I also agree not to hold responsible Tri-State Camp and/or Camp Maurer for any and all losses, claims, actions, or rights of action which may hereafter be made by me or on my behalf arising from or growing out of injuries claimed to have been sustained by me during my participation at Tri-State Camp. *
• Interns are not campers nor are they full staff members; they are interns serving Christ as they serve others and learn to model Christ-like-ness 24/7. • Interns will work alongside experienced staff, put in long hours and help in any number of areas including:- setting up and/or assisting with recreation, - helping lead dorm room devotions, assisting Counselors- assisting in the dining hall and helping with pack-up clean-up- any other task as may be requested by the Intern Program Coordinator • Participants will be required to attend a Special Orientation on the first day of Camp • Applications must be submitted to the Tri-State Board no later than June 15. • Participants will be asked to contribute $200.00 toward the expense of room and board - some limited scholarships may be available.• A $20.00 application fee must accompany completed applications and will be deducted from the room & board cost or refunded if the applicant is not accepted.• Acceptance will be made in writing no later than July 1. • The Tri-State Board reserves the right to limit the number of Interns *
Required
If you are a student-School enrolled in
Current Employer
Pastor *
Church
Pastor's Phone # *
Reference Name *
Reference  Email and/or Phone Number *
Relationship to applicant *
Describe your salvation experience *
How would describe the Bible
Describe your current participation in church *
Describe your spiritual growth experiences in the last year *
Describe your experiences at Camp Tri-state or other christian camps *
What experience do you have working with students? *
Describe any specific skills, training or certifications that you have
Describe activities and/or service opportunities of special interest to you
The next three questions are highly personal but necessary. If you would rather discuss these questions rather than answer them in writing, please contact the Tri-State Camp Director or Tri-State Board President. Answering yes, leaving the questions blank or discussing the questions will not automatically disqualify an applicant.
Have you ever been arrested for, charged with, under probation for, or convicted of either sexual or physical abuse?  
If yes, please explain
Have you ever been served with a temporary or permanent Restraining Order?
If yes, please explain
Were you a victim of sexual or physical abuse or molestation while a minor?
If yes, please explain
Have you ever used another name for any reason?
If yes, please explain
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