Last Name *

First Name *

Social Security Number (US Only) *

Date of Birth *

Home Phone *

Cell Phone *

E-mail Address *

Parent Name *

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Permanent Street Address *

City *

State *

Zip Code *

Select A State Other/International Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Ontario Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Street Address

City

State

Zip Code

Select A State Other/International Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Ontario Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

What do you presently do full time?

Synagogue at which you are a member

What kind of camp job(s) interests you?

Age group most comfortable with:

Name of College or Post High School Institution *

Major Area

Years Attended

Name of High School *

Current Grade *

Expected or Actual Graduation Date

Employer / Location           Please begin with most recent

Dates

Supervisor Name & Phone#

Describe Work

Employer / Location

Dates

Supervisor Name & Phone#

Describe Work

Camp Name / Location  1      

Dates

As a Camper or Staff Member?

Director's Name & Phone#

Camp Name / Location 2

Dates

As a Camper or Staff Member?

Director's Name & Phone#

References

List 3 PROFESSIONALS – school administrator, guidance counselor, dean of student activity, camp supervisor, youth group director, community service supervisor, current / previous employer (NOT RELATED) - who can comment on job/character/reliability abilities. Please print out and send THIS REFERENCE FORM to each person you list below.  All three must be returned to us directly by the reference!

(1) Name / Relationship *

Phone # or Email Address *

(2) Name / Relationship *

Phone # or Email Address *

(3) Name / Relationship *

Phone # or Email Address *

Arts & Crafts

Computers

Cooking/Baking

Sports Instruction

Woodshop

Music

Chinuch

Drama

Dance

Boating (Sailing & Canoeing)

  Dining Room / Food Service

Specify areas of athletic expertise

Athletics

Please list all relevant certification

Swim/Guard

Please specify

Other

Have you ever been convicted of a felony? *

 Yes 

 No 

Have you ever been charged and/or convicted of a crime involving physical, sexual or mental abuse of a child? *

 Yes

 No

What contribution do you believe you can make at camp?

Please explain how camp relates to your personal & professional goals:

Please list any youth organizations with which you are affiliated.

I affirm that all the information provided is true and accurate:

YES

NO

Submit my choices

 I'd like to start again