Please Fill Out & Complete All Fields
Note: Use "TAB" Key and/or Pointer to Move Between Fields

Name:
Date of Birth (MM/DD/YY):
Address:
Town:
Zip Code:
Telephone #:
Cell Phone # :
Social Security:
Email:
Education
Are you attending:	High School College
School year as of September:
Major or intended major:
Camp Experience
Please list any camp experience you have and any skills you can teach (example: Arts n Crafts, photo, music, drama, gymnastics, rock climbing, boating, nature, mountain biking, karate, etc...)
If you can teach swim, please list qualifications:
Age group prefered:	Please choose Nursery 6-10 10-14
Have you ever been convicted of a felony or a misdemeanor?	Yes No
Has you drivers license ever been suspended?	Yes No
License Number:
References Other Than Relatives
Name:
Relationship:
Telephone#:
Name:
Relationship:
Telephone#:
Name:
Relationship:
Telephone#:
Additional Comments and/or Information: