Staff Application

PERSONAL DATA

First Name:

Middle Name: not initial

Last Name:

SSN:

Permanent Address:

City:

State:

Zip:

Phone:

Age and gender are critical occupational qualifications for the following positions: Cabin Counselor/Activity Instructor, Trip Leader, Activity Specialist. If you are applying for one of these positions, please answer the following 2 questions:

Your Date of Birth: (mm/dd/yy)

Your Gender:

Male

Female

If you are applying for a position other than counselor or trip leader, please answer the following:

18 Yrs. or Older?:

Yes

Current Email Address:

Available Dates this Summer:

through

Applying For:

Salary Desired:

How Did You Hear About Us?: (Please be as specific as you can. If you found us on the Internet, please tell us which job listing service or search engine you were using.)

CURRENT OR PREVIOUS EDUCATIONAL INVOLVEMENT

School:

Your Address at School: (if different from above)

City:

State:

Zip:

Phone:

Your Email at School: (if different from above)

Current Year In College:

Major Field of Study:

At Which Address Can You be Reached for the Next Several Days?

School

Permanent

EMPLOYMENT INFORMATION

Are you currently employed?

Yes

Employer:

Supervisor:

Employer Phone:

Type of Job:

Is your employer aware you may resign for the summer?:

Yes

Our staff positions require that you be mobile over a variety of terrain and engage in physical exercise with campers. Do you have any physical restrictions that would prevent you from performing these duties?

Yes(If Yes, please explain below)

Current certifications you may have:

Certification:		Expiration (mm/dd/yy):
	W.S.I.
	Life-Guard Training
	Wilderness First Responder
	E.M.T.
	First Aid
	CPR
	Ropes Course
	Climbing Wall Belay/Instructor
	SCUBA Dive Master
	SCUBA OWSI

What age group of campers would you like to work in a cabin group/live with?

8 - 10 yrs.	11 - 12 yrs.	13 - 14 yrs.	15 yrs.	Any/no preference

Camp Skills

Prior Experience with Kids or Other Relevant Experience or Qualifications:

Activity Areas you are Qualified to Lead or Assist

Activity Name	Can Lead	Can Assist	Please explain your experience with this skill.
Archery
Arts & Crafts
Baseball
Basketball
Canoeing River
Canoeing Lake
Drama
Fishing
Golf
Guitar
Gymastics
Horse Riding (English)
Kayaking
Model Rocketry
Photography (Digital)
Pottery
Riflery
Rock Climbing
Ropes Courses
Sailing
SCUBA (Dive Master or OWSI)
Soccer
Swimming
Tennis
Waterskiing
Waterski Boat Driver
Weight Lifting

Experience with Kids

Please list any courses you have taken that may relate to working with kids:

Please describe your philosophy on how to successfully raise a child today:

Please describe any experiences you have had that may be of benefit to our campers:

Have you had any other work experiences supervising children? Please be as detailed as possible and list the name(s) of your employer(s)

How do you think a camper would describe you to his parents at the end of the summer? How do you think he would describe you to his friends at home?

What do you believe is the most compelling reason why we should hire you to be a staff member at Camp Timberlane?

Work/Camp Experience

If you have ever worked in a children's camp before, please complete the chart below:

	Camp #1 (most recent)	Camp #2
Name of Camp
Location of Camp
Director Names(s)
Camp Phone
Your Years There (i.e. 1999 - 2001)
Last Position Held
Salary

Please list below any other jobs you have held, including the dates you were employed, the firm's phone number, and the name of the employer or direct supervisor whom we can call as a reference. Please list your most recent or current employment first.

	Company	Dates of Employment	Phone	Employer/Supervisor
Latest Job
2nd Job
3rd Job

Background Check

Please provide three persons (not relatives or significant others) who have knowledge of your character and ability. Please note that we must be able to contact these references by phone or email to consider you for a position.

	Reference 1	Reference 2	Reference 3
Name
City/State
Phone #
Email
Relationship

Your Internet Presence

The Internet is Public Space. This includes social networking websites. We are interested in protecting our campers, our camp reputation, and our staff. So that we can learn about your presence on the Internet, and view any of your postings that would be readily viewed by campers and parents, please list any sites you are present on, and any username or logon information we need to view those public spaces.

	Site 1	Site 2	Site 3
Internet Site
Your Name on this Site
Any other information to help us locate your presence on this site

I acknowledge that I am the one who completed this application (fullname):

By submitting this form to Camp Timberlane, you certify that you have never been convicted of a crime including crime against a child or children, and have never been dismissed from any employment for this reason. You further give permission to Camp Timberlane to conduct criminal background evaluations at its discretion to confirm this information, and to review your public Internet postings. You further acknowledge that any future employment agreement between you and the camp is dependent on the satisfactory completion of these background steps.

If you agree with the statement above, please check the box prior to submitting this form. We know this application process is challenging, and we thank you for your time and interest. I agree

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