Name:  		   

E-mail:  	   

Permanent Address: 
Town/State/Zip:      

Home Phone:         Cell Phone:  

Current Address:   
Town/State/Zip:    


Date of Birth:          Married/Single:    

Age:  Yrs.    Weight:  Lbs.     Height:  Ft.  In.

               (Pennsylvania  State Human Rights Law forbids discrimination

                  on account of race, color, creed, sex, national origin or age)

High School Attended:  
Year of Graduation:     
Colleges:              
College Status:        
n/a 
Freshman 
Sophomore 
Junior 
Senior 
Completed 

Continuing Education:  
n/a 
In Grad. School 
Grad. School Completed 

Teaching Certificate:  
y/n
Yes 
No



Experience with children in schools, clubs, etc.

Camp experience, if any (Name camps and years)
Indicate whether as Camper, Junior Counselor or Counselor




Special Abilities: Select a "number" after those activities in which you have experience:

                                        1=leader; 2=good knowledge; 3=fair

  Team(s) played on, letters and awards (give full details):

 
 

  What activity would you like to teach at camp:

 

    References (personal and business) - please include addresses and phone numbers

 Reference No. 1:
 

 Reference No. 2:
 

  Referred by:      Relationship:      U.S.Citizen:

  Remarks (anything you wish to add):


 
 Ever filed an application with us before? No Yes     Date: 
 Ever been employed with us before?                No Yes     Date:


             Do you hold any certification, training, experience, or college coursework
                                                    in any of the following areas?

  Emergency Medical Technician
  Red Cross Lifeguard
  Water Safety Instructor
  National Rifle Association Instructor

  Commercial Driver's License

 Other: