Name: Moms Support Group
Start: 2019-11-12T08:30:00+00:00
End: 2019-11-12T10:00:00+00:00
Location: Lift Disability Network

Crew Member General Information
Name*
First Middle Last
Preferred Name*
First
Maiden Name
Last
Address*
Street Address Address Line 2 City State ZIP Code
Primary Phone*
Work Phone
Cell Phone
Email*
Enter Email Confirm Email
Emergency Contact Information
Emergency Contact*
First Last
Relationship*
Emergency Contact Address*
Street Address Address Line 2 City State ZIP Code
Emergency Contact Phone*

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)*
Employer*
Name of Company
(if not employed put N/A in all fields)
Employer's Address*
Street Address Address Line 2 City State ZIP Code
Job Title and Description*
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*

Child of Crew Member Application
Child's Name*
First Middle Last
Preferred Name*
First
Address*
Street Address Address Line 2 City State ZIP Code
Last Grade of School Completed*
Parent of Child*
Is the Crew Member the Parent or Legal Guardian?*
- Yes
- No
If not who is?
Address of Parent/Gaurdian if not Crew Member*
Street Address Address Line 2 City State ZIP Code
Email
Date of Child's Birth*
Date Format: MM slash DD slash YYYY
Gender*
- Male
- Female
Age*

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*
Type Full Name
Parent or Legal Guardian Signature Date (for searches conducted on minors under the age of 18)
Type Full Name
Date*
Date Format: MM slash DD slash YYYY

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 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
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FL Winter Retreat Crew Member Application

Your cost for this incredible weekend is $199.00.

2020 FL Winter Retreat Crew Application

Step 1 of 8 - General Information

Crew Member General Information

Emergency Contact Information

Crew Member General Information

References

Medical History

Skills

Spiritual Journey

Child of Crew Member Application

Child's Medical History

Additional Information

DISCLOSURE AND AUTHORIZATION FORM TO OBTAIN BACKGROUND REPORTS FOR VOLUNTEER PURPOSES

BACKGROUND REPORT AUTHORIZATION

General Authorization

First Name	Last Name	Phone	Email