General Personal Information
First Name
Last Name
Age by June 2010
Sex
Male
Female
Date of Birth
Social Security Number
Height
Weight
Allergies?
Contact Information
Home Phone Number
Cell Phone Number
Email Address
Current Mailing Information
Current Mailing Address
Current City
State
--- Choose One ---
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Current Zip Code
Permanent Mailing Information
Permanent Mailing Address
Permanent City
State
--- Choose One ---
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Permanent Zip Code
Family Information
Are you married?
Yes
No
Do you have children?
Yes
No
Age Child 1
Sex Child 1
N/A
Male
Female
Age Child 2
Sex Child 2
N/A
Male
Female
Age Child 3
Sex Child 3
N/A
Male
Female
Miscellaneous Information
Will you have a car at camp?
Yes
No
Do you smoke?
Yes
No
Drivers License State
--- Choose One ---
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Drivers License Number
Present Occupation
Education Information
Name of College
Major
Expected Graduation Date
Please list any certifications.
Legal Information
Have you ever been arrested or convicted of a criminal offense, or at the present time are you the subject of a criminal investigation?
Yes
No
If yes, please provide a detailed explanation:
Have you ever been charged with or convicted of sexual abuse or molestation?
Yes
No
Work Experience and Leadership Roles
Please list the names of the companies you worked for, dates of employment, salary, and duties.
References
Name 1
Phone Number 1
Email 1
Relationship 1
Name 2
Phone Number 2
Email 2
Relationship 2
Name 3
Phone Number 3
Email 3
Relationship 3
Specialty Activities
Click YES if you qualify as an expert in the applicable activity and could effectively lead instruction in it.
Land Sports
Baseball
YES
NO
Basketball
YES
NO
Football
YES
NO
Hockey
YES
NO
Lacrosse
YES
NO
Soccer
YES
NO
Softball
YES
NO
Volleyball
YES
NO
Individual Sports
Archery
YES
NO
Cheerleading
YES
NO
Go-Carts
YES
NO
Golf
YES
NO
Gymnastics
YES
NO
Karate
YES
NO
Mountain Biking
YES
NO
Tennis
YES
NO
Track
YES
NO
Weight Training
YES
NO
Creative Arts
Ceramics
YES
NO
Cooking
YES
NO
Jewelry
YES
NO
Leatherwork
YES
NO
Painting
YES
NO
Rocketry
YES
NO
Woodworking
YES
NO
Water Sports
Canoeing
YES
NO
Diving
YES
NO
Fishing
YES
NO
Kayaking
YES
NO
Motorboat Driving
YES
NO
Sailing
YES
NO
Swimming
YES
NO
Waterskiing
YES
NO
Performing Arts
Costuming
YES
NO
Dance
YES
NO
Drums
YES
NO
Guitar
YES
NO
Music
YES
NO
Piano
YES
NO
Play Direction
YES
NO
Set Design
YES
NO
Sound/Light Board
YES
NO
Vocal
YES
NO
Adventure
Camping
YES
NO
Nature
YES
NO
Orienteering
YES
NO
Rock Climbing
YES
NO
Ropes Courses
YES
NO
Do you have any camp experience? If so, please elaborate.
Do you have any experience with children? If so, please elaborate and include ages.
Personal Statement
Located in Thompson, PA | Coed 4 and 7 week session | Site designed by
Sebago Visions
