PUTNAM COUNTY KIDS COUNT

CHARACTER

Counselor Application 2017   PRINTABLE FORM

Character Day Camp Application 2017

 

Due May 17th Return to:          North Putnam HS Office

Email to chuddleston@ccrtc.com

Heritage Lake POA Office

 

Check position for which you are applying:

_____ Assistant Counselor- volunteer (grades 9 & 10)

_____ Counselor (grades 11,12 or experience)

Camp Dates – June 12 to 16

 

Name __________________________________________Nickname_______________

Permanent Address/City/Zip_______________________________________________

Email___________________________________Date of Birth____________________

Phone____________________________Cell___________________________________

(   ) Male   (   ) Female                                    Adult Shirt Size_____________________

 

Emergency Contact ___________________________Relationship________________

Phone_______________________________________Cell________________________

 

Education

School     Course of Study    Graduate OR Year Completed          Degree

 

 

 

 

Volunteer/Work Experience—Past & Present

 

 

 

 

3 References, not relatives with knowledge of your character & ability

Name                                            Phone                                     Affiliation

 

 

 

 

Special Skills, Hobbies, Talents, Interests, Training

 

 

          Please circle Grade preferences to work with:

    K        1st       2nd       3rd       4th         5th        Middle School

 

 

 

Relate any summer/day camp experiences & activities (&/or working with children grades K-8)

 

 

 

 

Have you ever been arrested, charged or received a notice or summons to appear for any criminal violation?        _____ Yes     _____ No

Have you ever been convicted of a felony?     _____ Yes     _____ No

Have you ever received a ticket or been charged with a traffic violation (excluding parking tickets)?     _____  Yes     _____  No

Provide details for each response to the above questions.

________________________________________________________________________________________________________________________________________________________________________________________________________________________                               

  

I understand that the ______________with Character Day Camp Program is a drug free work place.  If asked, I agree to a blood, hair, and/or urine test for non-prescription controlled substances and to submit samples for such tests whenever so requested.  I authorize investigation of all statements herein and release the camp and all others from liability in connection with same.  I understand that, if selected, I will be a volunteer and that any agreement to the contrary must be in writing and signed by the camp coordinator.  I also understand that untrue, misleading or omitted information herein may result in dismissal, regardless of the time of discovery by the camp. 

 

I further understand that if selected, I will be required to complete a Criminal History Information Authorization Form allowing the _____________with Character Day Camp Program Coordinator, or its representative, to conduct a state and county criminal history check.

 

I agree to a required interview to be conducted for the purpose of counselor selection. 

 

Signature___________________________________________________________

 

Print Name _________________________________________________________

 

Date___________________________________

 

The ______________Character Day Camp Program is an equal opportunity employer and does not discriminate in employment because of race, color, national origin, ancestry, sex, religion, age, sexual orientation or any other characteristic protected by federal, state or local law.

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