In accordance with the Children's Online Privacy Protection Act a person must be 13 years of age or older to complete and submit this form.

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

 
Name:
Home Telephone :
Permanent Address :
City:
State:
Zip:
Present Address :
City:
State:
Zip:
Date of Birth:
Social Security #:
Email:

(New York State Human Rights Law forbids discrimination on account of race, color, creed, sex, national origin or age. Americans with Disabilities Act of 1990 forbids discrimination against qualified people with disabilities.)
Are you able to participate in sports and physical activities: Yes No
If your answer is no, why not?:

Emergency Information

Emergency Contact's Name:
Address:
Phone #:
Relation:

School Information

High School Attended:
Year of Graduation:
College/s attending/ed:
Degree/s Granted (as of June):
What Level:
College/Business Address:

Experience
Experience with children in Schools, Clubs etc.:

Camp Experience, if any

  
Camp Name:
What Years :
Position: (Camper, Junior Counselor, Counselor)
 
Camp Name:
What Years :
Position:(Camper, Junior Counselor, Counselor)
 
Camp Name:
What Years :
Position: (Camper, Junior Counselor, Counselor)
Special Abilities: Put a 1 before those activities in which you have experience as a leader; 2, a good knowledge; 3, fair.

Archery
Aerobics
Art
Baseball
Basketball
Bowling
Ceramics
Crafts
Computers
Cooking
Dancing

Dramatic
Gymnastic
Karate
Cheerleading
Music
Nature
Newspaper
Photography
Racquetball
Rocketry
      		Singing
Soccer
Swimming
Radio
Tennis
Volleyball
Water Sport
Woodworking
Adventure Challenge
High/Low Course

Give full details-teams played on, letter and awards.
What would you like to do at camp?
Salary per season at last camp
(if any):
Years teaching experience:
Where did you teach?
References (No Relatives):
Reference 1:
Address:
Phone:
Relation to applicant:
 
Reference 2:
Address:
Phone:
Relation to applicant:
 
Reference 3:
Address:
Phone:
Relation to applicant:
 
Reference 4:
Address:
Phone:
Relation to applicant:
 
Reference 5:
Address:
Phone:
Relation to applicant:
 

Other Information :
 
Married or Single (please check one)
Remarks (anything you wish to add; hobbies, interests, etc.)
Availability:
Full Day
AM PM
Summer
Will there be a child involved in coming with? Yes No
If so, please give their names and ages:
Do you hold any certifications, training, experience, or college coursework in any of the following areas?
(Provide dates where possible)
CPR/BLS Dates:
EMT Dates:
Nassau County Certification Dates:
First Aid Dates:
Water Safety Instructor Dates:
Lifeguard Training Dates:
 
Years Driving:
Driver's License Number:
Do you currently hold a Commercial Driver's License? Yes No
 
Where did you hear about us?
 
Have you ever been arrested for any crime including sex related or child abuse related offenses?
 
(Returnees) have circumstances changed since you filed your last application?
 

The undersigned authorizes the camp to contact any previous employers and personal references. Your opportunity for employment will be based solely upon your merit and the availability of positions.

Please enter name, this is in essence your online signature.
I certify that all the information provided on this application is true and free of falsehood.
  This field helps prevent automated access.
 
Enter the code as it is shown: