All God’s Children Camp - Mentor Application page 2 of 4
All God’s Children Camp 2009 Mentor Application
for children of incarcerated mothers
choose one of three week-long overnight camps for children ages 7 – 12
August 2 - 7 Camp Highroad in Middleburg
August 9 - 14 Westview on the James in Goochland
August 16 - 21 Occohannock on the Bay in Belle Haven
Please complete and return this form to:
Ann Davis, Director of Children’s Ministries & Discipleship
The Virginia Conference United Methodist Church
PO Box 1719
Glen Allen, VA 23060
804-521-1138 or 1-800-768-6040 ext. 138
Name Date of Birth*
first middle last month day year
Home Address
street or PO box city state zip code
Email Address
Home Phone # Work Phone # Gender
*must be 17 or older at time of camp
Church attending
Address
street or PO box city state zip code
Church Phone # Pastor
Previous residence(s) for last 5 years (include college and home residences):
address city state years
Part I
1. Do you agree to do the following if accepted as a mentor:
a. Attend the entire camp week. Select Camp (check at least one)
Camp Highroad q August 2 - 7
Westview on the James q August 9 - 14
Occohannock on the Bay q August 16 - 21
b. Attend the training scheduled for the
Sunday morning of your camp week? Yes or No
c. Be willing, able, and eager to participate in a physical outdoor
residential camping experience with children? Yes or No
d. Be willing to participate in an emotionally challenging experience
with children who have a variety of discipline problems? Yes or No
e. Communicate with your campers after summer for at least one year? Yes or No
f. Be in prayer for the camping program? Yes or No
2. Have you been a mentor at the All God’s Children Camp before? Yes or No
If yes, what was the last year you mentored? ______
3. Why would you like to be a mentor, or why would you like to return to camp as a mentor?
(Please include where you are on your faith journey and how willing you would be to share
your faith with a child, caregiver, and mother. Attach separate sheet if needed.)
4. Please enclose with this application form a letter of reference from a pastor or leader
in your religious community if possible, or from a community leader or director of a
community organization, employer, teacher, or professor. (Not needed if a returning mentor)
List two other references (one employment or teacher if student, and one personal non-related):
Other Reference #1:
Name Relationship How long known?
Address Phone #
Other Reference #2:
Name Relationship How long known?
Address Phone #
Part II
In keeping with Virginia Conference Child Protection Guidelines, you must answer the following questions:
1. Have you ever been convicted of a misdemeanor or felony
(including driving violations)? Yes or No
If yes, please explain:
2. Have you ever been convicted of any crime of violence against minors? Yes or No
If yes, please explain:
3. Have you ever been adjudged liable for civil penalties or
damages involving sexual or physical abuse of children? Yes or No
If yes, please explain:
4. Are you subject to any court order involving sexual or physical abuse of a
minor, including but not limited to a domestic order of protection? Yes or No
If yes, please explain:
5. Have your parental rights ever been terminated for reasons
involving sexual or physical abuse of children? Yes or No
If yes, please explain:
I understand that:
a. The camp may deny a mentor opportunity to any person who answers
any of the questions of Part II in the affirmative.
b. In applying for a mentor position the information which I have furnished on this form
is subject to verification, which will include a criminal history check and request
from any Central Registry of child abusers.
c. The camp may terminate volunteer service of any person:
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•Found to have a history of complaints of abuse of a minor and/or
•Found to have resigned, been terminated or been asked to resign from a position,
•either paid or volunteer, due to complaint of sexual abuse of a minor.
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By signing this form, I attest to the fact that the information I have provided is truthful.
Signature Date