STAFF APPLICATION FORM

Date of Application
Full Name
E-mail Address
Age (Check One) <18 18+ 21+

Permanent Address:
Dates/Times expected to be at this address
Street and Number
City
State
Zip
Phone

 

 
School or Winter Address:
Dates/Times you can be reached at this address
Street and Number
City
State
Zip
Phone

EDUCATION

Years Attended School Major Subjects Degree Granted

PAST EMPLOYMENT (List previous two summers or years)

Dates Employer Nature of Work Supervisor
Employer Address
Reason for Leaving
Dates Employer Nature of Work Supervisor
Employer Address
Reason for Leaving
Dates Employer Nature of Work Supervisor
Employer Address
Reason for Leaving

Indicate any employer you do not wish us to contact and the reason

CAMP EXPERIENCE

Dates Camp Director
Address Camper or Staff?  
Camper

Staff

  
Dates Camp Director
Address Camper or Staff?  
Camper

Staff

  

REFERENCES (Give names/addresses of 3 persons [not relatives] having knowledge of your character, experience and ability.)

Name
Address & City
e-mail
(if available)
Phone

Applicants 21 and older:

Do you drive? Yes No Valid driver's license? Yes No
In what state issued?

Are there any reasons you may have difficulty in performing any of the
essential elements of the job for which you have applied?
Yes
No

If yes, explain:

Dates available to work From
 To
What position(s) are you applying for?
Weekly salary desired?

Considering the camp program and position applying for, put numeral "1" before those activities you can organize and teach; "2" for those activities which you can assist in teaching; and, "3" for those which you are interested in.

Recreation/Outdoor Living Skills

Basketball
Soccer
Archery
Hiking
Field Games
Volleyball
Outdoor Living Skills
Overnight Camping
Initiative Challenges
Low Ropes Course

Nature/Agriculture

Pond life
Woodland life
Forestry
Birds
Horseback Riding
Barnyard Animal Care
Science Experiments
Other

Creative Arts

Painting
Drama Activities
Nature Crafts
Other
Lead Singing
Storytelling
Dance (type)
Play Directing
Instruments (list)
Skits and Stunts

Waterfront

Swimming Instruction (WSI)
Kayaking
Canoeing
Water-related Games

Other Activities

Cultures
Campfire Program
Evening Activities
Woodworking
Other

Certifications/Special Training (First Aid, CPR, Life Guard Training, Archery, Ropes Course, etc.):
Please provide date when received and expiration date.

What contributions do you think you can make at camp?

What contributions do you think a well-run camp can make to children?

Have you ever been convicted of a crime in which a child was the victim?

Yes No

If yes, please explain

Write a brief biographical sketch, including specialized training experience or training in other fields which might have a bearing on the position for which you are applying.

I agree Important: Clicking this checkbox signifies my agreement that to the best of my knowledge, the above information is factual and accurate.

In accordance with Massachusetts law, summer camps are required to obtain a criminal background report on all staff working with children. Part of the application process will require you to authorize 4-H Camp Middlesex to receive this information about you.
I authorize investigation of all statements herein and release the camp and all others from liability in connection with same. I understand that untrue, misleading, or omitted information herein may result in dismissal, regardless of the time of discovery by the camp.

Note: All statements become part of any employee personnel files.

 

 

 

4-H Camp Middlesex
PO Box 185, 1031 Erickson Rd.
Ashby, MA 01431
Tel: (978) 386-7704 Fax: (978) 386-7046
office@campmiddlesex.com