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1 Name: Date: / / Last First Month Day Year S.S.N: - - GENERAL FORMA Current Address: Date of Bih(if under 18): / / City: State/Zip Code: Home Phone: Cell Phone: Permanent Address (if different from above address): City: State/Zip Code: Home Phone: A) Medical Information: Self pay/no insurance Company: Policy Number: Activity Restrictions: Health Concerns (describe concerns and/or check off boxes below): Diabetes Physical Handicap Emotional Handicap Asthma Insect Stings Seizures Nervous Disorders Cardiac Hay Fever Epilepsy Other Emergency Contact: Name: Relationship: Home Phone: Work Phone: Cell Phone: Education (completed education): High School: Year Graduated: College/Trade School: Fr So Jr Sr Gr Degree/Major: Other Education: Degree: Work Status: Pa time Full time Student Employer: Address: Are you a citizen of the United States? Yes No Date available for employment: Graduation year: Year Graduated: Occupation: Work Phone: City/State/Zip: If no, are you authorized to work in the U.S.? Yes No MISTRY How would you like to be involved at Urban Impact? Please mark your preferences with a. I would like to be an/a: Assistant Teacher Lead Teacher Team Leader Rank in order of preference the age groups with which you are most comfoable: grades 1-3 grades 4-6 grades 7-8 1

2 MP DAS FOR 2014 ARE JUNE 1 July 31. ARE YOU AVAILABLE THESE DAS? YES NO Please list any exceptions. Do you have first aid or CPR ceificates? If yes, date of expiration: Do you have a Life Guard ceificate? If yes, date of expiration: Have you been pa of other UIF ministries? yes no Are you currently involved? yes no If yes, which ministry? If no, why did you stop? How/where did you learn about Urban Impact? What size T-shi do you wear? A) EMPLOYMENT/MISTRY EXPERIENCE List volunteer, work, military experience and college extracurricular activities and attach a resume. In column 1 please place a * by your most relevant job experience and an x: by your least favorite experience. 1 Company/Church/School Job/Activity Description Contact Name & Number Dates 2

3 NT S STAMENT I ceify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be helpful in arriving at an employment decision. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with Urban Impact Foundation is of an at will nature, which means that the employee may resign at any time and the employer may discharge the employee at any time with or without cause. It is fuher understood that this at will employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized representative of Urban Impact Foundation. In the event of employment, I understand that false or misleading information provided in my application or interview(s) may result in discharge whenever discovered. I understand, also, that I am required to abide by all policies and procedures set foh by Urban Impact Foundation, and that these policies and procedures are subject to change without notice. I hereby release any and all former employers and references from any liability for releasing information about me. If you are selected to work in camp and sign a letter of commitment, do you consider your signature binding? Yes No Your Signature: Date: Parent/Guardian Signature (if under 18) Date: ORGANIZAAL DOCTRE At UIF we believe everyone is in process with the Lord. Our understanding of God is one of those areas in which we are constantly growing. We are interested in where you are on your journey. Please read the following beliefs about God which UIF affirms. After reading, please respond in the space provided with the following: (1) Are these beliefs consistent with your own beliefs? (2) About which if any of these beliefs do you remain unsure about? Why so? ABOUT THE SCRIPTURES: We believe the entire Bible is the inspired Word of God and that men were moved by the Spirit of God to write the very words of Scripture. Therefore, we believe the Bible is without error in its original manuscripts. ABOUT GOD: We believe in one God who exists in three distinct persons: Father, Son, and Holy Spirit. ABOUT JESUS: We believe that Jesus Christ is fully God and fully human. We believe that He was born of a virgin. We believe that He lived a sinless life. We believe that His miracles were true. We also believe that He died in the place of sinners on a cross, that He was truly resurrected, and ascended back to heaven. 3

4 ABOUT THE HOLY SPIRIT: We believe in the personality and deity of the Holy Spirit. We believe He gives life, He sanctifies, He empowers and comfos all believers. We believe the Holy Spirit indwells believers in Christ. We believe that it is through the power of the Holy Spirit that we are born again, and that the work of the Spirit includes convicting us of sin and empowering us to be righteous. ABOUT MANKD: We believe that mankind was created in the image of God. God gave Adam, the first man, specific commands that were to be obeyed. Through his sinful disobedience to these commands, Adam and the whole human race were alienated from God. As a result, man is incapable of regaining a right relationship with God through his own effo. ABOUT SALVA: We believe that, as a result of The Fall, all men are lost and separated from God because of sin. For this reason, we believe that man is saved only through repentance and faith in the finished work of Christ. Therefore, in order to experience salvation, even those who have never heard the name of Jesus Christ must hear of Christ and understand who He is to be saved. We believe that, when we repent and express faith in this manner, we are declared not guilty before God by His grace alone, are born again, receive the gift of eternal life, and become children of God. ABOUT THE CHURCH: We believe the Church is the body of Jesus Christ, and it is composed of all true believers, with Christ as the Head of the body. We believe that, while on eah, believers must join themselves to other Christians in visible local assemblies. We believe these local assemblies are also the Church, for it is in these local assemblies that the work of the Church is carried out. The present work of the Church is the worship of God, the loving and teaching of people, and making Him known to a lost world. We believe the purpose of the Church is to glorify God. ABOUT CHRIST'S RETU: We believe in the personal and bodily return of the Lord Jesus Christ. His return will complete and establish the ongoing enjoyment of our salvation in His glorious Kingdom. 1) Are the beliefs stated above consistent with your own beliefs: (Circle One) YES NO SOMEWHAT 2) [If selecting No or Somewhat above] Which, if any of these beliefs do you remain unsure about? Why so? 4

5 PERSAL AND SPIRITUAL HISTORY Describe your relationship with your parents and siblings. What church do you attend? How many years? B) Describe your church in one sentence. Write a brief testimony about how you came to know Jesus Christ as your personal Savior. Describe recent areas of recognized growth in your day-to-day Christian life. Have you ever led anyone to Christ for the first time, or discipled someone so that they grew in their walk with God? Explain how it happened most recently. 5

6 Have you served or paicipated in any discipleship programs, mentoring relationships, or youth ministries, whether presently or in the past? What accountability do you currently have in your spiritual journey? B) As representatives of Christ, we are urged in Ephesians 4:1 to live a life wohy of [our] calling. This includes resisting lifestyles and temptations that our society may deem acceptable. What decisions have you made, and boundaries have you set in order to honor God and live a life above reproach? Are there any special issues or concerns happening in your life right now that would have an impact on your commitment and involvement in the youth ministry (e.g. relationships, other commitments, etc.)? What do you see as your spiritual gifts/talents? Please share your motivation in desiring to intern with Urban Impact. Temperament (circle one): A. Around others I am more: Reserved or Outgoing B. My decisions are based more on: Facts/thinking or Feeling/thinking C. In my relationships I tend to be more: Dependent or Independent D. I tend to focus on the: Big Picture or Details E. I tend to have: Lots of good friends or A few close friends F. My use of time is more: Determined or Spontaneous G. I feel most comfoable in: Large crowds or Small groups 6

7 Conflict: Would you consider yourself good at handling confrontation? yes Why? no How do you handle it when someone else confronts you? B) What do you do when you have a conflict with someone? Describe a situation in which you took a position in leadership. Into what career or ministry do you sense God is leading you? In what ways would a summer position with Urban Impact help you prepare for this career or ministry? How do you see yourself contributing to the staff? 7

8 PERSAL EVALUA Please rate yourself and check the appropriate box beside each character trait. B) Quality Submit to authority Good listener Easily understood Compassionate Dependable Lead a Christian lifestyle Encourage Flexible Initiate conversation Have integrity Model good judgment Organize time Have a positive attitude Problem solve Punctual Relational with children / youth Have a servant hea Team player Embrace diversity in others 2 Sometimes 3 Most of the time 4 Usually 5 Without fail Describe your most challenging experience working with children and how you handled the situation. Please include their age group. 8

9 SKILLS Do you have experience doing the following? If yes, please explain the context in which you learned/performed/lead. B) Activity Years of Context involvement Leading Worship Planning and performing skits Leading as and crafts Organizing and facilitating group games Leading Bible studies Playing/Coaching spos Playing a musical instrument Tutoring Leading outdoor activities Using administrative skills Other activity experience: Dance Overnight Camping Teaching math Teaching literacy Planning big events Computers/technical experience Audio/Visual Equipment REFERENCES Please list two references to whom you will be sending the reference form. Please include a pastor. Remember to attach an addressed and stamped envelope when you distribute the reference form. References should not include family members. Name: Name: Phone Number: Phone Number: 9

10 Summer Day Camp Referral Urban Impact Foundation 801 Union Avenue, 4 th Floor, Pittsburgh, PA Phone: Fax: amanda.wagner@urbanimpactpittsburgh.org Dear, I am applying for a summer position with Urban Impact Foundation which is a faith based community development organization. If hired, I will be working with children and youth in the summer day camp. As pa of the application process, two references are required. Thank you for taking your time to help me complete this requirement. Applicant signature Printed Name Urban Impact Foundation Summer Day Camp is faith based non-profit organization located on the Noh Side of Pittsburgh and serves an urban population. Our camp is attended by 160 children and youth in grades 1-8. The camp day includes Christian education, academic remediation in math and reading, physical activity and improving social skills. Our camp staff to camper ratio is 1:6. The staff teaches and/or assists with the above segments along with handling discipline issues, supervising field trips, interacting with parents, and repoing to coordinators and UIF staff. The camp is eight weeks long and runs from 8:30am-4:00pm. The campers attend all eight weeks giving us the oppounity to build relationships and to impact lives in the city, one person, one family, one block at a time. Thank you for agreeing to be a reference for the above applicant and for taking your time to complete this form. If you have any questions or concerns, please feel free to reach me at Amanda Wagner Program Supervisor Urban Impact Foundation Strongly Please evaluate the applicant. disagree Christian Education The applicant has a personal relationship with Christ The applicant can teach a Bible lesson The applicant can develop a Bible lesson The applicant can assist with a Bible lesson Academic The applicant is an excellent student The applicant has good study habits The applicant can teach a math lesson The applicant can assist with a math lesson The applicant can teach a literacy lesson The applicant can assist with a literacy lesson Physical The applicant is physically active The applicant is in vigorous health Social/leadership The applicant can maintain order in a classroom The applicant is fair The applicant is asseive Disagree Agree Strongly agree Don t know 10

11 How long have you known the applicant? Less than 1 year 1-4 years 5-9 years 10 or more years What is your relationship with the applicant? Pastor teacher friend Other Please rate the applicant and check the appropriate box beside each character trait. Submission to authority Good listener Easily understood Compassionate Dependable Christian Lifestyle Encourage Flexible Initiate conversation Integrity Model good judgment Organize time Positive Attitude Problem solve Punctual Relational with children or youth Servant hea Team Player Embrace diversity in others Half the time Sometimes Most of the time Usually Without fail What do you consider to be the applicant s strongest leadership quality? What do you consider to be an area of growth for the applicant? Please share three adjectives that describe the applicant.,, Do you have any concerns about this applicant working with young children? yes no If yes, please explain. All information contained in this reference shall remain confidential. I appreciate your time to complete this form. If there is other information that you would like to share, please include it on the back of this page. Please sign and date. If a return envelope has not been provided, please return this form to: Amanda Wagner, Urban Impact Foundation, 801 Union Avenue, 4 th Floor, Pittsburgh, PA Signature Print Name Date 11

12 Summer Day Camp Referral Urban Impact Foundation 801 Union Avenue, 4 th Floor, Pittsburgh, PA Phone: Fax: amanda.wagner@urbanimpactpittsburgh.org Dear, I am applying for a summer position with Urban Impact Foundation which is a faith based community development organization. If hired, I will be working with children and youth in the summer day camp. As pa of the application process, two references are required. Thank you for taking your time to help me complete this requirement. Applicant signature Printed Name Urban Impact Foundation Summer Day Camp is faith based non-profit organization located on the Noh Side of Pittsburgh and serves an urban population. Our camp is attended by 160 children and youth in grades 1-8. The camp day includes Christian education, academic remediation in math and reading, physical activity and improving social skills. Our camp staff to camper ratio is 1:6. The staff teaches and/or assists with the above segments along with handling discipline issues, supervising field trips, interacting with parents, and repoing to coordinators and UIF staff. The camp is eight weeks long and runs from 8:30am-4:00pm. The campers attend all eight weeks giving us the oppounity to build relationships and to impact lives in the city, one person, one family, one block at a time. Thank you for agreeing to be a reference for the above applicant and for taking your time to complete this form. If you have any questions or concerns, please feel free to reach me at Amanda Wagner Program Supervisor Urban Impact Foundation Strongly Please evaluate the applicant. disagree Christian Education The applicant has a personal relationship with Christ The applicant can teach a Bible lesson The applicant can develop a Bible lesson The applicant can assist with a Bible lesson Academic The applicant is an excellent student The applicant has good study habits The applicant can teach a math lesson The applicant can assist with a math lesson The applicant can teach a literacy lesson The applicant can assist with a literacy lesson Physical The applicant is physically active The applicant is in vigorous health Social/leadership The applicant can maintain order in a classroom The applicant is fair The applicant is asseive Disagree Agree Strongly agree Don t know 12

13 How long have you known the applicant? Less than 1 year 1-4 years 5-9 years 10 or more years What is your relationship with the applicant? Pastor teacher friend Other Please rate the applicant and check the appropriate box beside each character trait. Submission to authority Good listener Easily understood Compassionate Dependable Christian Lifestyle Encourage Flexible Initiate conversation Integrity Model good judgment Organize time Positive Attitude Problem solve Punctual Relational with children or youth Servant hea Team Player Embrace diversity in others Half the time Sometimes Most of the time Usually Without fail What do you consider to be the applicant s strongest leadership quality? What do you consider to be an area of growth for the applicant? Please share three adjectives that describe the applicant.,, Do you have any concerns about this applicant working with young children? yes no If yes, please explain. All information contained in this reference shall remain confidential. I appreciate your time to complete this form. If there is other information that you would like to share, please include it on the back of this page. Please sign and date. If a return envelope has not been provided, please return this form to: Amanda Wagner, Urban Impact Foundation, 801 Union Avenue, 4 th Floor, Pittsburgh, PA Signature Print Name Date 13