2023 Breakaway Crew Application

Crew Member Contact Information

Legal Name*

First Middle Last

Preferred First Name*

Gender*

Male

Female

Maiden Name*

Date of Birth*

MM

DD

YYYY

applicant must be over 16

Age*

Are You Married?*

Yes

No

Social Security Number*

Used to conduct a criminal background check in accordance with current standards concerning volunteers.

Primary Phone Number*

Secondary Phone Number

Home Address*

Street Address Address Line 2 City State ZIP Code

Email*

Enter Email Confirm Email

Emergency Contact Information

Emergency Contact's Name*

First Last

What is the Emergency Contact's Relationship to You?*

Emergency Contact's Primary Phone*

Emergency Contact's Secondary Phone

Is this your First Time applying for BREAKAWAY:*

Yes

No

Pastoral Reference

Pastor's Name*

First Last

Pastors Phone*

Pastors Email*

Non-Related Adult Reference #1

Reference #1 Name*

First Last

Reference #1 Phone*

Reference #1 Email*

Non-Related Adult Reference #2

Reference #2 Name*

First Last

Reference #2 Phone*

Reference #2 Email*

Employer Information

Are you currently employed?*

Yes

No

Employer*

Name of Company

Job Title and Description*

Employer's Address*

Street Address Address Line 2 City State ZIP Code

Skills

Although experience is not necessary please list any experience you have had with people with disabilities. Also please tell us of any talent or certifications you may have that could be useful at BREAKAWAY. (i.e.: CPR Certified, EMT, Life Guard Certified, Sign Language, Sing or Play an instrument)

Skills*

Please list your areas of interest: (age group (Infant, Elementary, Youth, Adult) arts, technical)*

General Volunteering Info

Family Members or Name of Group

Please list all family members that will be with you, or the name of the group you are part of (if applicable):

Will any of your children ages 6-15 be serving with you?*

Yes

No

Roomate Request

First Last

Spiritual Journey

Please describe your relationship with Jesus Christ:

Spiritual Journey*

Additional Information

What is the best way to utilize your gifts this week?*

What are your areas of interest?*

Can you follow instructions?*

Yes

No

Sometimes

Do you have any behavioral issues?*

Yes

No

Explain Behavioral Issues*

DISCLOSURE AND AUTHORIZATION FORM TO OBTAIN BACKGROUND REPORTS FOR VOLUNTEER PURPOSES

Please Read Carefully Before Signing the Authorization DISCLOSURE In considering you as a volunteer, Lift Disability Network will order a background report about you that we obtain from a consumer reporting agency, Protect My Ministry, Inc. The background report may contain information concerning your character, general reputation, personal characteristics, and mode of living. The types of information that may be ordered include but are not limited to: Social Security number verification; criminal, public, educational and, as appropriate, driving records checks; verification of prior employment; reference, licensing and certification checks; and drug testing results. The information may be obtained from private and public record sources, including personal interviews with your associates, friends, and neighbors. (An “investigative consumer report” is a background report that includes information from such personal interviews, except in California where that term means any background report.) Under the FCRA, before the Company can obtain a background report about you for employment or volunteer purposes, we must have your written authorization. Before we take adverse action on the basis, in whole or in part, of information in that report, you will be provided a copy of that report, the name, address, and telephone number of the consumer reporting agency, and a summary of your rights under the FCRA.

BACKGROUND REPORT AUTHORIZATION

I have read and understand the foregoing Disclosure, and authorize LIFT DISABILITY NETWORK to obtain and rely upon background reports in considering me as a volunteer. By my signature below, I authorize Lift Disability Network to obtain any such reports and to share the information received with any person involved in the volunteer decision about me. I also agree that this Disclosure and Authorization in original, faxed, photocopied, or electronic (including electronically signed) form will be valid for any consumer reports that may be requested about me by or on behalf of Lift Disability Network.

Name*

First Last

Applicant Signature*

Please Type Full Name

Date*

General Authorization

PLEASE READ CAREFULLY, AND SIGN THAT YOU UNDERSTAND AND ACCEPT THIS INFORMATION. I will be present at Crew Member Orientation the day before BREAKAWAY and will notify Lift Disability Network as soon as possible in the event I am not able to attend the week I have applied for. I have given my Social Security # for the release of my criminal records to determine acceptance and have given consent on the Authorization Form. I will show respect for all staff members and families, and I understand that the BREAKAWAY Director has the right to dismiss any Crew Member in the best interest of BREAKAWAY. Permission is given only to Lift Disability Network to use photographs (individual or group) and/or multi-media images and recordings in the best interest of Lift Disability Network. I understand that photographs/video/images I take at any BREAKAWAY/Lift Disability Network function are for my personal use only. Personal internet use of any video/media should be approached with caution with regard to misrepresentation.  I realize I am responsible for my own actions during the designated time period of BREAKAWAY, and that my legal protection under the Volunteer Protection Act covers my actions only when I am following the written policies and procedures of Lift Disability Network.  I will be a constructive member of the Staff, being a Christ-like example in all my actions, contributing in every way to the unity and purpose of the BREAKAWAY.  I will always have another adult present when I am with children and youth and will never be alone with a child under the age of 18.  I will pray daily for BREAKAWAY and each person in my care.  I realize that tobacco, alcohol, and illegal drugs are NOT ALLOWED.  I understand that all staff, including myself and all participants, have limited insurance coverage against injury or illness only. Therefore, if my misconduct results in a lawsuit, I understand I will represent myself. I shall indemnify Lift Disability Network and its staff, and hold them harmless from and against liability or responsibility for my negligence or misconduct.  I understand that participation includes possible exposure to and illness from infectious diseases including but not limited to MRSA, influenza, and COVID-19. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist; and,  I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and,  I willingly agree to comply with the stated and customary terms and conditions for participation as regards protection against infectious diseases. If, however, I observe and any unusual or significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately.  I authorize Lift Disability Network to contact all prior employers and any references listed herein to verify all information provided and to obtain any and all information related to my character and past work performance. I release all references and prior employers from any liability for information provided in good faith.  The information contained in this application is correct, to the best of my knowledge. I have read the above statements and agree to cooperate with Lift Disability Network and the BREAKAWAY Staff.

Signature*

Type Full Name

Captcha

Your cost for this incredible week is $475.00.

Crew Member Contact Information

Emergency Contact Information

Crew Member General Information

Pastoral Reference

Non-Related Adult Reference #1

Non-Related Adult Reference #2

Employer Information

Medical History

Health Insurance Company

Primary Doctor

Skills

General Volunteering Info

Spiritual Journey

Additional Information

DISCLOSURE AND AUTHORIZATION FORM TO OBTAIN BACKGROUND REPORTS FOR VOLUNTEER PURPOSES

BACKGROUND REPORT AUTHORIZATION

General Authorization