Staff Application

First Name
Last Name
Gender	Male Female
Birth Date
Age as of 6/30/02
Grade Completed as of 6/02
Social Security #
School Attending
Home Address
City
State
Zip Code
Phone Number
E-Mail Address
College Address  (if applicable)
City
State
Zip Code
Phone Number
E-Mail Address
Educational Background:
High School
Dates Attended
College/University
Dates Attended
Area of Study
Please List and Explain any Leadership Experience You Have Had
References (List 3)
Reference #1
Address
Phone Number
Name
Address
Phone Number
Reference #2
Address
Phone Number
Reference # 3
Address
Phone Number
Group/Area Preference	Ruth/Moses (3rd-5th Grade) Rebecca/Dan (6th & 7th Grade) Leah/Abe (8th & 9th Grade) Specialty Health Center Kitchen Pool Office Maintenance
If You Chose "Specialty," Which Activity Would You Prefer?
If You Chose "Pool,"	Please Indicate Appropriate Certification Information:
Lifeguard Training	Expires
Basic Life Support	Expires
Water Safety Instruction	Expires
CPR	Expires
First Aid	Expires
Do You Have Any Physical Limitations or Illnesses?	Yes	No
If Yes, Please Explain
Are You a Smoker?	Yes	No
Do You Have Any Special Dietary Needs?	Yes	No
If Yes, Please Explain
Have You Ever Been In an Incident Involving the Sexual or Physical Abuse of Children?	Yes	No
If Yes, Please Explain
Have You Ever Been Convicted of a Felony or Misdemeanor	Yes	No
If Yes, Please Explain
Please Give Careful Thought to the Next Few Questions:
If you ever attended a Residential/Sleepaway Camp, Please Give the Name and Location
Some Experiences With Children That I Have Enjoyed Are:
Elements That I Find Essential to Building a Positive Community:
Challenges That I Anticipate Facing While Working as a Counselor:
Personal Strengths That I Anticipate Utilizing at Camp:
I Hope To Work At Camp Edward Isaacs in Order to Gain:
My Most Significant Jewish Experience Was:
Special Interests, Talents, Sports Skills, Hobbies, and Other Information:
By Submitting This Application I Attest That ALL the Information Contained Herein is True and Factual	Yes	No