Camp Program Staff Application
Fill in and SUBMIT online

Name
Social Security Number
Email
Date of Birth
Gender	Male  Female
Cell Phone Number
PERMANENT ADDRESS
Dates/Times Available at this Address
Street Address
City
State
Zip Code
Phone
SCHOOL OR WINTER ADDRESS
Dates/Times Available at this Address
Street Address
City
State
Zip Code
Phone
EDUCATION  Years Attended  School  Major Subjects  Degree Granted
PAST EMPLOYMENT - for past two summers or years    Job 1  Job 2  Job 3 Dates: Employer: Address: Phone: Nature of Work: Supervisor: Reason for Leaving:
Indicate any employer you do not wish us to contact and the reason
CAMP EXPERIENCE    Camp 1  Camp 2 Dates: Camp: Director: Address: Phone: Camper or Staff?: Camper   Staff   Both   Camper   Staff   Both
REFERENCES (Give names/addresses of 3 persons [not relatives] having knowledge of your character, experience and ability.)    Reference 1  Reference 2  Reference 3 Name: Address: City & State: Phone:
Which position are you applying for: Department Head    Waterfront    Nature    Arts & Crafts    Recreation Dates Available: From:     To: Program Counselor    Arts & Crafts    Nature    Barnyard    Lifeguard    Canoe/Kayak Instructor    Recreation    High Ropes    Archery
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, please explain:
Considering the camp program and position applying for, Select "1" for those activities which you can organize and teach. Select "2" where you feel you can assist in teaching.
Recreation/Outdoor Living Skills ? 1 2 Softball ? 1 2 Soccer ? 1 2 Archery ? 1 2 Hiking ? 1 2 Fishing ? 1 2 Field Games ? 1 2 Volleyball ? 1 2 Outdoor Living Skills ? 1 2 Survival ? 1 2 Orienteering ? 1 2 Overnight camping ? 1 2 Initiative Challenges ? 1 2 High Ropes Course ? 1 2 Climbing Tower Nature/Agriculture ? 1 2 Marine life ? 1 2 Pond life ? 1 2 Woodland life ? 1 2 Barnyard Animal Care ? 1 2 Birds ? 1 2 Insects ? 1 2 Aquaria Care ? 1 2 Small Animal Care ? 1 2 Forestry ? 1 2 Gardening Other Creative Arts ? 1 2 Leather Work ? 1 2 Painting ? 1 2 Pottery/Sculpting ? 1 2 Nature Crafts ? 1 2 Lead Singing ? 1 2 Storytelling ? 1 2 Dance (type) ? 1 2 Play Directing ? 1 2 Skits and Stunts ? 1 2 Instruments (list) Waterfront ? 1 2 Swimming Instruction ? 1 2 Canoeing ? 1 2 Kayaking ? 1 2 Snorkeling ? 1 2 Water-related Games Other Activities ? 1 2 Native American Culture ? 1 2 Campfire Program ? 1 2 Evening Activities 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. 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 Farley 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. Please type the letters shown in the box below: