COMPLETE AND RETURN TO:

Carlisle Family YMCA

311 South West Street

Carlisle, Pennsylvania 17013

Phone: 717-243-2525

Fax: 717-243-9293

APPLICATION FOR ALL JUNIOR & SENIOR

COUNSELOR POSITIONS

Please type your answers in the designated fields:

PERSONAL:

First Name Middle Name Last Name

*Email Address Phone Number Social Security Number

Current Street Adress City State Zip Code

Are you able, with reasonable accommodation, to perform the essential elements of the job

for which you are applying?

Which camp(s) are you interested in working with:

Are you legally authorized to work in the U.S.?

Inclusive dates you would be able to work: mm/dd/yr - mm/dd/yr

Have you ever been convicted of a crime?

If yes, describe in full.

EDUCATION:

Select the year or grade you will have completed by the end of the current school year:

High School/College(s) you are currently attending:

For what profession are you preparing?

Degree(s) Earned Concentration:

CAMP HISTORY / EXPERIENCE

Have you ever been a camper? If yes: Camp Name

Have you ever been part of a camp staff? If yes: Camp Name Position Year

The following are camp program skills: Put "1" before those activities you have an interest in; "2" to indicate those activities with which you have experience; "3" before those activities you can organize and teach.

Archery 0123 / Storytelling 0123 / Other Certifications or Trainings
Backpacking 0123 / Mountain Bike 0123 / -
Canoeing 0123 / Rock Climbing 0123 / -
Ecology/Nature 0123 / Sports 0123 / -
Fishing 0123 / Cooking 0123 / -
Games 0123 / Arts & Crafts 0123 / -
Hiking 0123 / Teambuilding 0123
Kayaking 0123 / Sailing 0123
Swimming 0123 / Song Leading 0123
Wilderness Trips 0123 / Music Instr. 0123

Certifications/Training

/

Expiration Date

_Lifeguard Training / mm/dd/yr
_Water Safety Instructor / mm/dd/yr
_Advanced First Aid / mm/dd/yr
_Standard First Aid / mm/dd/yr
_CPR / mm/dd/yr
_Community CPR / mm/dd/yr

I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for is cause for dismissal. Further, I understand and agree that my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without previous notice.

Please type your full name: Date: mm/dd/yr

*By printing your full name and date you agree to the terms of employment consideration by the Carlisle Family YMCA and its camps. Please refer to the paragraphs above for the terms of employment and employment consideration.

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