Please Fill Out & Complete ALL Fields
Note: Use the "TAB" Key and/or Pointer to Move Between Fields 

Name:   

Social Security #:  



Permanent Address:  

City:   

State:  

Zip:    

Phone:  



School/Business Address:  

City:   

State:  

Zip:    

Phone:  

Dates

From:   

To:     



E-mail:  



Birthdate:  

Best time to reach you by phone:  

Height:  

Weight:  

Any health or physical restrictions?  Yes  No

Explain:





With what age camper would you like to be a counselor?

7-10

11-12

13-15

No preference

Have you ever been convicted of any crime including child abuse or sexual
abuse? 

Education

High School:  

Major:        

Current Year:  



College:      

Major:        

Current Year:  



Past Employment - List previous two summers or years

Dates:     

Employer:  

Address:   

Phone:     



Dates:     

Employer:  

Address:   

Phone:     



Dates:     

Employer:  

Address:   

Phone:     



Camp Experience

Camp:      

Director:  

Address:   

Phone:     

Dates:     



Camp:      

Director:  

Address:   

Phone:     

Dates:     



References

Give names & addresses of 3 persons (not relatives) who have

knowledge of your character, experience and ability.

Name:     

Address:  

Relationship:  

Phone:    



Name:     

Address:  

Relationship:  

Phone:    



Name:     

Address:  

Relationship:  

Phone:    



What type of position are you applying for?  

Salary Desired:  $

Do you smoke?  Yes  No

Do you give permission for a criminal record check?  Yes  No



Dates Available

From:  

To:    



Have you any obligation requiring time away from camp?  Yes  No

If yes, explain:



Are you available for an interview?  Yes  No

Where?  

When?

In the following list, choose "1" for those activities you can organize and teach ALONE, and a "2" for those activities which you are familiar with and can ASSIST in teaching.
(You need not choose numbers for all of the activities)

Arts & Crafts
Ceramics:
Jewelry:
Leather Work:
General Crafts
Pottery:
Woodwork:
Other:

Music
Lead Singing:
Piano:
Guitar:
Other:

Water Activities
Drive Jet Ski:
Canoeing:
Diving:
Swimming:
Synchro. Swimming:
Water Polo: 		Sports
Archery:
Softball:
Basketball:
Fishing:
Gymnastics:
Hockey:
Riflery:
Soccer:
Tennis:
Volleyball:
Wrestling:
Lacrosse:
Golf:
Fitness Training:
Field Hockey:

Dramatics
Creative:
Directing:

Pioneering
Overnight Camping:
Scouting: 		Dancing
Ballet:
Modern/Jazz:
Aerobics:
Pilates:

Nature
Animals:
Trees & Plants:
Ecology:

Miscellaneous
Cooking:
Ropes Course:
Photography/Darkroom:
Worship Services:
Radio Station:
Rocketry:
Newspaper:
Chess:
Cheerleading:
Judo/Karate:
Climbing Wall:
Roller Blading:
Other:

CERTIFICATIONS EARNED:
Lifeguard Training
Water Safety Instructor
First Aid
CPR
Archery
Riflery
Other

List other:

What contribution do you think you can make at camp and what contribution do you think a well-run camp can make to children?

Write a brief biographical sketch, including camp experience, extra curricular activities, and training in outher fields which might have a bearing on the position(s) for which you are applying. (JV or Varsity Sports, Hobbies, etc.)