2017 Staff Application

2017 STAFF APPLICATION

Name:______Social Security#:______

Permanent Address:______

streetcity state zip

School Address(if different than above):______

street city state zip

Phone number(s): Home:______Cell:______

E-mail address:______

Birth Date:______/______/______Age as of August 31, 2017______

monthday year

In emergency, contact______

name and relationship phone

Present Occupation:______

Level of education completed by June 15, 2017______

school or college

______

majoryr. completed degree

Indicate any condition(s) that would restrict your work:

Do you have a criminal record or have you been arrested for child abuse/sexual assault?

If yes, explain:

Do you have a current driver’s license?______

yes/nonumber state

Do you have health insurance? ______

Will you be present for the entire camp season (June 26 – July 30)?

Yes or No______

How did you learn about Maine Arts Camp?______

Previous CampExperience:

Dates:______CampName______Position______

Other Youth related Experience:

Dates:______Organization______Position______

From the activity list below, name up to 5 activities (not categories) in order of your interest to teach. Foreach activity, rate your ability to teach, from 1-5, 5 being the highest (able to lead the

activity) and 1 being the lowest.

Fine Arts:anime, batik, beading, drawing, enameling, fabric arts, hand building, mask making, metal jewelry, painting, pottery, printmaking, puppetry, quilting, sewing, stained glass

Theater: acting, directing, improvisation, musical theater, stage combat

Dance:contemporary, hip hop, jazz, lyrical, modern

Music:guitar, piano/accompany, music ensemble, chorus,ukulele, other (indicate instrument)

Technology:digital photography, film photography, videography, robotics, rocketry, science

Individual sports:tennis, fencing, fitness, hiking, kayaking/canoeing, road biking, ultimate frisbee, yoga, zumba

Special Interests:culinary arts, creative writing, chess

1.______2.______3.______4.______5.______

For those activities you can lead, list your relevant background/experience (continue on back if necessary):

Any other activities of interest (continue on back if necessary)?

Why are you interested in working at Maine Arts Camp?

Current qualifications, certifications, licenses?

____First Aid_____C.P.R ______Lifeguard training_____Archery

_____A.R.C. Small craft/canoe

Other(s)______

References (Professional, Educational, Occupational)

1.______

namephone relationship

2.______

namephone relationship

3.______

namephone relationship

Please Read Carefully Before Signing the Authorization

DISCLOSURE

In considering you for employment, Bethel Camp for the Arts, LLC (dba Maine Arts Camp) may request and rely upon one or more consumer reports or investigative consumer reports about you that we obtain from a consumer reporting agency, such as IntelliCorp Records, Inc.

For explanation purposes:

a “consumer report” includes criminal history reports, driving violations and an address record. This is often described as a background check.

an “investigative consumer report” is a consumer report in which information on your character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with your prior employers/references you provide on the staff application.

AUTHORIZATION

I have read and understand the foregoing Disclosure, and authorize Maine Arts Camp to obtain and rely upon consumer reports or investigative consumer reports in considering me for employment. By my signature below, I authorize the Company to obtain any such reports and to share the information received with any person involved in the employment decision about me.

I authorize Maine Arts Camp to contact the references listed on the application for Employment and Reference Verifications

I also agree that this Disclosure and Authorization in original, faxed, photocopied, or electronic (including electronically signed) form will be valid for any consumer reports or investigative consumer reports that may be requested about me by or on behalf of the Company.

______

Applicant SignatureDate

Please return this form to the winter address below:

Maine Arts Camp

P.O. Box 812076

Boca Raton, FL 33481

Phone: 561-865-4330

E-mail: