Personal Information
Last Name: First Name: M.I.:
Maiden Name:
Date of Birth (optional):
E-mail address:
Present Occupation or Year in School:
Present Address (street, city, state, zip code):
Present Phone #:
Permanent Address if Different (street, city, state, zip code):
Permanent Phone #:

Camp Desired
Camp Pennyroyal
Bear Creek Aquatic Camp
Either

Camp Position Desired: (check one)
Asst. Camp Director
Boating Director/Coordinator
Waterfront Director/Aquatics Director
Waterfont Asst.
Boating Asst.
Unit Staff
Nurse/EMT
Head Cook
Asst. Cook
Kitchen Asst.

Education
Years: School:
Major Subjects:
Degree Earned:

Years: School:
Major Subjects:
Degree Earned:

Years: School:
Major Subjects:
Degree Earned:

Employment History (list two previous years or summers)
Dates: Position:
Employer & Supervisor:
Address and Phone #:
Reason for Leaving:

Dates: Position:
Employer & Supervisor:
Address and Phone #:
Reason for Leaving:

Dates: Position:
Employer & Supervisor:
Address and Phone #:
Reason for Leaving:

Indicate any employer you wish for us not to contact and reason:

Camp Experience
Dates:
Camp:
Director:
Address and Phone #:
Camper or Staff: Camper Staff

Dates:
Camp:
Director:
Address and Phone #:
Camper or Staff: Camper Staff

Dates:
Camp:
Director:
Address and Phone #:
Camper or Staff: Camper Staff

Certifications

Currently Have	Had, now Expired	Date of Expiration (if applicable)	Type	Misc. Information
			Driver's License	State: DL#:
			Commercial Driver's License	State: DL#:
			Standard First Aid
			Small Craft Safety-canoeing
			Community CPR
			Small Craft Safety-sailing
			CPR for Professional Rescuer
			Small Craft Safety-kayaking
			Lifeguard
			ARC Sailing Instructor
			Emergency Water Safety
			Basic Life Support
			Lifeguard Instructor
			Registered Nurse	State:
			Other	Other:
			Licensed Practical Nurse	State:

Skills
In the following list, write a letter "C" by those activities in which you have current certification. Put a number "1" by those activities you can organize and teach as an expert, "2" by activities in which you can assist in teaching, and "3" by those which are your hobbies.
Campcraft
Firebuilding
Outdoor Cooking
Overnight Camping
Minimum Impact Camping
OLS Program Leader
OLS Instructor
Hiking
Orienteering
Backpacking
Other:

Waterfront Activities
Canoeing
Kayaking
Diving
Rowing
Sailing
Swimming
Motor boats
Windsurfing
Whitewater Rafting
Water Skiing
Other:

Adventure/Challenge
Climbing/Rappelling
Ropes Course
Spelunking/Caving
Teams Course
Other:

Arts and Crafts
Basketry
Ceramics/Pottery
Jewelry Making
Nature Crafts
Weaving
Woodworking
Other:

Sports
Archery
Informal Games
Horeseback Riding
Mountain Biking
Other:

Dancing
Type:
Type:

Dramatics
Creative
Play Directing
Skits and Stunts
Campfire Programs
Storytelling

Nature
Conservation
Project Wild
Project Learning Tree
Project Wet
Animals
Plants/Flowers/Trees
Astronomy
Other:

Music
Song Leading
Instrument:

Other Skills or Hobbies Related to Camp:

Open Response Questions
What can you contribute to our camp?

What contributions do you think a well-run camp can make in children's lives?

Describe any work, volunteer, educational, or other experiences you have had that relate to the position for which you are applying. How do theses experiences make you better qualified for this camp job?

Professional References
Give the names, addresses, and phone numbers of four professional references of people (not relatives) that have knowledge of your skills, experience, and character. Suggested references include current or former supervisors of paid or volunteer experiences, professors, coaches, etc. -- or, other people who have known you in a professional capacity. Three of these should be the names of the people to whom you are giving the reference sheets.

Name: Title and/or Relationship to You:
Phone Number:
Address:

Name: Title and/or Relationship to You:
Phone Number:
Address:

Name: Title and/or Relationship to You:
Phone Number:
Address:

Name: Title and/or Relationship to You:
Phone Number:
Address:

Misc
Have you ever been convicted of a crime (other than traffic violations)?
Yes No
If yes, please state offense, date, and location. (A conviction will not necessarily be cause for disqualification.)

Are there any reasons why you may have difficulty in performing any of the essential functions of the job for which you applied? Yes No
If yes, please explain.

If hired, would you desire or need housing for any person(s) other than yourself at camp? Yes No
If yes, please give details.

If hired, would there by any dates you would not/might not be available to work?
Yes No
If yes, please explain and give all dates.

Seasonal salary desired:

Are you available for an interview in person? Yes No
If yes, where?

When is the best day/time to reach you by phone?

If you have an e-mail account, how often do you check it?

I understand that a certificate of physical examination is a prerequisite for employment. Under penalty of immediate dismissal, I certify, by submitting this information, that the information contained in this application is true to the best of my knowledge. I give permission to Girl Scouts of Kentuckiana to request a confidential background check with law enforcement agencies for any conviction information concerning me.

Please review all data before submitting.