Please fill out the fields that follow. Use your "TAB" key to move down the page.

PERSONAL INFORMATION
First Name:       
Last Name:        
SS#:              

Present Address:
Address:    
City:       
State:      
Zip:        
Phone:      
Expiration Date of Present Address:  

Permanent Address:
Address:    
City:       
State:      
Zip:        
Phone:      

If you are hired, would you desire or need housing
for any person(s) other than yourself at camp?  Yes     No

Position Desired
Please state the position for which you would like to be considered:

BACKGROUND

EDUCATION
School:          
Dates Attended:  
Major:           
Degree Granted:  

School:          
Dates Attended:  
Major:           
Degree Granted:  

School:          
Dates Attended:  
Major:           
Degree Granted:  

WORK EXPERIENCE
Job Title:         
Employer:          
Telephone:         
Dates Employed:    
Responsibilities:  

Job Title:         
Employer:          
Telephone:         
Dates Employed:    
Responsibilities:  

Job Title:         
Employer:          
Telephone:         
Dates Employed:    
Responsibilities:  

LEADERSHIP EXPERIENCE
Describe


CAMP EXPERIENCE AS A CAMPER OR CAMP STAFF MEMBER
Camper/Staff?  N/ACamperStaff
Camp Name:     
Employer:      
Address:       
Dates:         

Camper/Staff?  N/ACamperStaff
Camp Name:     
Employer:      
Address:       
Dates:         

Camper/Staff?  N/ACamperStaff
Camp Name:     
Employer:      
Address:       
Dates:         

AREA OF EXPERTISE
In the following list:
Select a "1" for all activities you are able to organize/teach
Select a "2" for all activities you are able to assist in teaching
Select a "3" for all activities you consider to be just a hobby

ADVENTURE

Backpacking:       N/A 1 2 3 
Bicycle Trips:     N/A 1 2 3 
Camp Craft:        N/A 1 2 3 
Hiking:            N/A 1 2 3 
Orienteering:      N/A 1 2 3 
Outdoor Cooking:   N/A 1 23 
Overnight Camping: N/A 1 2 3 
Ropes Course:      N/A 1 23 
Survival Skills:   N/A 1 2 3 

ARTS/CRAFTS

Ceramics:       N/A 1 2 3 
Crafts:         N/A 1 2 3 
Drawing:        N/A 1 2 3 
Jewelry Making: N/A 1 2 3 
Journalism:     N/A 1 2 3 
Metal Work:     N/A 1 2 3 
Painting:       N/A 1 2 3 
Photography:    N/A 1 2 3 
Pottery:        N/A 1 2 3 
Stained Glass:  N/A 1 2 3 
Video:          N/A 1 2 3 
Weaving:        N/A 1 2 3 
Woodworking:    N/A 1 2 3 

Animal Care:        N/A 1 2 3 
Astronomy:          N/A 1 2 3 
Computers:          N/A 1 2 3 
Ecology:            N/A 1 2 3 
Farming/Gardening:  N/A 1 2 3 
Nature Study:       N/A 1 2 3 
Radio/Electronics:  N/A 1 2 3 
Rocketry:           N/A 1 2 3 
Weather:            N/A 1 2 3 

Aerobics:      N/A123
Ballet:        N/A123
Folkdance:     N/A123
Mod/Jazz Dance:N/A123
Instr. Music:  N/A123
Singing:       N/A123
Directing:     N/A123
Skits:         N/A123
Stagecraft:    N/A123
Theater Arts:  N/A123

Canoeing/Kayaking:   N/A 1 2 3 
Diving:              N/A 1 2 3 
Rowboating:          N/A 1 2 3 
Scuba/Snorkeling:    N/A 1 2 3 
Swim:                N/A 1 2 3 
Waterskiing:         N/A 1 2 3 
Windsurfing:         N/A 1 2 3 

Health Care:    N/A 1 2 3 
Food Service:   N/A 1 2 3 
Maintenance:    N/A 1 2 3 
Driving:        N/A 1 2 3 
Office Skills:  N/A 1 2 3 

Archery:             N/A 1 2 3 
Baseball:            N/A 1 2 3 
Basketball:          N/A 1 2 3 
Field Hockey:        N/A 1 2 3 
Floor Hockey:        N/A 1 2 3 
Football:            N/A 1 2 3 
Games:               N/A 1 2 3 
Golf:                N/A 1 2 3 
Gymnastics:          N/A 1 2 3 
Horseback Riding:    N/A 1 2 3 
Ice Hockey/Skating:  N/A 1 2 3 

Lacrosse:         N/A 1 2 3 
Martial Arts:     N/A 1 2 3 
Non-Comp. Games:  N/A 1 2 3 
Riflery:          N/A 1 2 3 
Soccer:           N/A 1 2 3 
Softball:         N/A 1 2 3 
Tennis:           N/A 1 2 3 
Track/Field:      N/A 1 2 3 
Tumbling:         N/A 1 2 3 
Volleyball:       N/A 1 2 3 
Wrestling:        N/A 1 2 3 

Do you hold current certification in the following areas:

Life Saving:  N/A    Yes    No
If "Yes", date certified:  

First Aid:  N/A    Yes    No
If "Yes", date certified:  

Water Safety Instruction:  N/A    Yes    No
If "Yes", date certified:  

CPR:  N/A    Yes    No
If "Yes", date certified:  

Do you hold a current Driver's License:  Yes    No
Has your license ever been suspended:  Yes    No
If so, why?


Describe your experiences or training which may have a bearing
on the position for which you are applying:


How do you hope your camp experience will enhance your own life?


REFERENCES
List 3 individuals, not related to you, who have knowledge
of your character, experience and ability.

Reference 1
Name:            
Address:         
City/State/Zip:  
Position:        

Reference 2
Name:            
Address:         
City/State/Zip:  
Position:        

Reference 3
Name:            
Address:         
City/State/Zip:  
Position:        

Have you ever been convicted of a crime within the past five years?  Yes    No
If "Yes", please explain:


E-mail Address: