Due April 29th Return to: North Putnam HS Office
Email to firstname.lastname@example.org
Heritage Lake POA Office
Check position for which you are applying:
_____ Assistant Counselor- volunteer (grades 9th & 10th)
_____ Counselor (grades 11th,12th or experience)
Camp Dates – June 13th to 17th
Email___________________________________Date of Birth____________________
( ) Male ( ) Female Adult Shirt Size_____________________
Emergency Contact ___________________________Relationship________________
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.
Print Name _________________________________________________________
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.