In accordance with the Children's Online Privacy Protection Act a person must be 13 years of age or older to complete and submit this form.

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

Are you applying to be a counselor or a CIT? Counselor CIT

			
Last Name *:     
First Name *:     MI 
Email Address *: 

Name called:   
Date of birth:    

Social Security Number: 

Church Affiliation:  Church Activities: 
Permanent Address:    
City:  
State:
Zip:    
Phone #: 

College Address/PO:    
City:  
State:
Zip:    
Phone #:    Fax #: 
Are there any reasons you may have difficulty performing any of the essential elements
of the job for which you are applying? Yes  No
If yes, please explain. Have you ever been convicted of any law violation? Yes  No
If yes, please explain. 
Education
Years
High School & College
College Major
Degrees
Camp Experience
Dates
Camp 
Name 
Address/City/ST/Zip
Director
Camper 
or Staff
Past Employment
Dates
Employer
Address/City/ST/Zip
Nature 
of work
Area Code/Ph# 
References
(Do not list relatives or peers)
Name
Address/City/ST/Zip
Area 
Code/Phone # 

In the following list, put a numeral "1" before those activities you can organize and teach as an expert;
 "2" for those activities in which you can assist in teaching; "3" for those which are just your hobby.

Adventure/Challenge
N/A
1
2
3

Climbing/Rappelling
N/A
1
2
3

Ropes Course
N/A
1
2
3

Belaying


Arts and Crafts
N/A
1
2
3

Jewelry/Beads
N/A
1
2
3

Woodworking
N/A
1
2
3

Leather Work
N/A
1
2
3

Nature Crafts
N/A
1
2
3

Painting
N/A
1
2
3

Model Railroading


Outdoor Living Skills (OLS)
N/A
1
2
3

OLS Program Leader
N/A
1
2
3

OLS Instructor
N/A
1
2
3

Hiking
N/A
1
2
3

Orienteering
N/A
1
2
3

Outdoor Cooking
N/A
1
2
3

Overnight Camping
N/A
1
2
3

Minimum Impact Camping

Dancing
N/A
1
2
3
Country Line
N/A
1
2
3

Folk
N/A
1
2
3

Square
N/A
1
2
3

Other 

List 

Dramatics
N/A
1
2
3

Creative
N/A
1
2
3

Skits/Stunts
N/A
1
2
3

Play/Directing

Music
N/A
1
2
3

Lead Singing
N/A
1
2
3

Instruments
N/A
1
2
3

Guitar
N/A
1
2
3

Piano
N/A
1
2
3

Banjo


Miscellaneous
N/A
1
2
3

Digital Photography
N/A
1
2
3

Video Photography
N/A
1
2
3

Power Point Presentations
N/A
1
2
3

Pagemaker Software
N/A
1
2
3

Adobe Photoshop Software
N/A
1
2
3

Pagemaker Software
N/A
1
2
3

Worship Services

Sports
N/A
1
2
3
Archery

Archery Certification 

Yes

No
N/A
1
2
3

Baseball/Softball
N/A
1
2
3

Basketball
N/A
1
2
3

Biking
N/A
1
2
3

Cheerleading/Gymnastics 
N/A
1
2
3

Fishing
N/A
1
2
3

Bait Casting
N/A
1
2
3

Fly Casting
N/A
1
2
3

Golf
N/A
1
2
3

Informal Games
N/A
1
2
3

Lacrosse
N/A
1
2
3

Mountain Boarding
N/A
1
2
3

Ping Pong
N/A
1
2
3

Riding - Horseback

Instructor Certification

Yes

No
N/A
1
2
3

Radio Control Cars
N/A
1
2
3

Riflery

NRA Instructor

Yes

No
N/A
1
2
3

Soccer
N/A
1
2
3

Tennis
N/A
1
2
3

Track & Field
N/A
1
2
3

Volleyball 

Waterfront Activities
N/A
1
2
3
Canoeing
N/A
1
2
3
Kayaking
N/A
1
2
3
White Water Rafting


N/A
1
2
3
Swimming Instructor
N/A
1
2
3
Water Skiing


N/A
1
2
3
Lifeguard Training
Certification Type & Date
N/A
1
2
3
Ski Boat Driving
# Hours Experience

CPR/1st Aid:Please 
note date of first aid and CPR certification
N/A
1
2
3
First 
Aid Certification: Date & Type
N/A
1
2
3
CPR Certification: 
Date & Type


COUNSELOR APPLICANTS:
Are you interested in ropes ranger training week? Yes No 
Do you have a current lifeguard certification? Yes No 
If not, are you interested in lifeguard training?	Yes No 


Are you applying to work all sessions this summer? Yes No

If you are applying to work a partial summer, please indicate all sessions you are available to work.

	ROPES RANGER TRAINING	MAY 23-27
	COUNSELOR ORIENTATION	MAY 23-27
	SESSION 1 (S1)	JUNE 8-12
	MINI-CAMP (MC)	JUNE 21-27
	SESSION 2 (S2)	JUNE 29-JULY 11
	SESSION 3 (S3)	JULY 13-25
	SESSION 4 (S4)	JULY 27-AUG. 8

Are you available for an interview? Yes No
 If so, where/when? 
            

Please write a brief biographical sketch, including specialized training in camping, and experience or training in other 
fields which might have a bearing on the position for which you are applying. Include the contributions you feel you 
can make at Camp Bear Track and the contribution you think a well run camp can make to children.



Additional Comments:


I authorize investigations of all statements herein and release the camp and all others from liability 
in connection with the same. I understand, that if employed, I will be an at-will employee and that any 
agreement to the contrary must be in writing and signed by the directors of the camp. I also understand 
that untrue, misleading, or omitted information herein may result in dismissal, regardless of the time 
of discovery by the camp.

	Please, enter the text that you see in the picture:
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