CAMP DATES: JUNE 8-11, 2017

STAFF APPLICATION

(CAMP STAFF MUST BE AT LEAST 18 YEARS OF AGE)

New location: Camp Michawana (west of Lansing)

5800 Head Lake, Hastings, MI 49058

Please return completed application to:

Cheryl Van Vliet, cell 313.460.3194

1576 Walnut Ridge Cr

Canton, MI 48187

Name: ______Nickname: ______

Address: ______

Street, City, State & Zip

Phone: (Home) ______Cell or Work Phone: ______

Email: ______Female: ______Male: ______

If you are a first time Counselor, please provide personal references we may contact: List two (2)

non-relatives who know about your interaction with children/youth. (Required by law.)

Name Address Phone

1.  ______

2.  ______

In case of emergency notify: ______

Relationship: ______Phone: ______

Address: ______

Health Insurance Co.: ______Policy No.: ______

Are you a Civitan: ______Club Name: ______

Education: (List most recently completed.)

Name of Institution Grade or Degree Year

______

Are you currently a student? ______Where: ______

How did you learn about Camp Civitan-Michigan? ______

______

List hobbies and interests that may be useful at Camp: (water sports, crafts, music, signing, dancing, or a special workshop you could lead, etc.)

______

______

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List any recent camp staff experience:

Camp Location Dates

______

______

Please list experiences you have had working with people who have developmental disabilities and

briefly tell why you want to be a staff member at Camp Civitan-Michigan.

______

______

______

I understand and agree to the following:

1.  I will arrive at Camp on Thursday, June 8th by 1:00 pm, prior to arrival of the campers, remain on the Camp site until Sunday, June 11th and will not leave Camp until my group leaves on Sunday.

2.  I understand that this Camp is a non-smoking environment.

3.  If I am currently on prescription drugs, I will notify the camp nurse what I am taking and the reason for taking them.

4.  I will be responsible for my own transportation to and from Camp.

  1. I understand that the Camp Directors will send me a letter of acceptance along with the necessary information concerning camp.

T-shirt size: ______

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Print name Date

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Signature