Camp Staff Application

 

Name                                                                                                                                       Date         /       /          

                Last                                                                         First                                                         Middle

 

Address                                                                                                                                                                       

            Street                                                                                                                                                                                       Apt. Number

 

                                                                                                                                                                       

City                                                                                                      State                                        Zip Code

 

Phone   (           )                                    (          )                                   (           )                                                             

                  Home                                                           Work                                                       Cell

 

E-Mail Address                                                                                                                                                              

 

Social Security Number                         -                       -                                               Sex:  Male   Female

Have you ever been convicted of a felony or misdemeanor?  Yes  No  

If yes, please explain:                                                                                                                                                    

 

Position Applying For: (please check one)

 

___ Physician               ___ Nurse Practitioner              ___ Registered Nurse               ___Pharmacist 

           

___ Physician Asst.      ___ Fellow in Training               ___ Respiratory Therapist         ___ Other                                

 

How did you hear about camp?                                                                                                                                     

 

Have you worked at camp before?                      Yes  No If yes, for how many years?                                          

 

Do you have experience with asthma?                 Yes  No If yes, explain                                                                

Do you have experience working with kids?         Yes  No  If yes, explain                                                               

 

Why would you like to work at camp?                                                                                                                             

                                                                                                                                                                                   

 If applicable, does your liability insurance cover you while working at camp?         Yes  No

 

Professional Information

    Type of License or Registration           Registration or License Number                      Expiration Date

 

 

 

 

 

*Please attach copies of any relevant license, registration or certification

 

Education History

                                                           Name and Location of School       Major Course of Study                 Diploma/Degree                  

High School

 

 

 

 

 

College/University

 

 

 

 

 

Graduate/Professional

 

 

 

 

 

Employment History

                               

                                                                                                   Dates                                           May We   Phone                         

   Company and Address              Position                From    To        Supervisor                  Contact?   Number             Reason for Leaving      

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

Please provide three references (relatives excluded)

 

   Name                                                                    Address                                                                                Phone Number    

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I certify that the information in this application is true and complete and that I have not knowingly withheld any fact or circumstance that would, if disclosed, affect my application unfavorably.  I understand that any false information submitted in this application may result in my discharge.  I understand and agree that any offer is contingent on successful completion of a background check and satisfactory references.

 

I hereby authorize                                                                                to investigate all statements contained in this application, including references.

 

                                                                                                                                                                                                                                               
Signature                                                                                                                                               Date

 

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