The National Conference for Community
and Justice of the Piedmont Triad, Inc.
713 North Greene Street
Greensboro, NC 27401
713 voifgpoirt
CounselorApplication for NCCJ 2015ANYTOWN Program
NCCJ ANYTOWN Counselorsmust have previously attended the ANYTOWN Program as an ANYTOWN Delegate. Throughout the week at Blowing Rock Conference Center (BRCC), Counselors are expected to be actively engaged by working well with other staff members, teaching songs, planning skits, contributing positively to delegate morale, leadingsmall discussion groups and supporting daily programs.
Please type or print legibly.
Name ______
______
Address (where you want your mail to go) City State Zip
______/______/______
Home Phone Mobile Phone Date of Birth
Primary email address ______T-shirt Size ______
Current School and Class Year (if applicable):______
To ensure diversity at ANYTOWN, we ask that you please check any / all of the following that apply to you: (This information is confidential and will be viewed by NCCJ staff only. It will not be used or disclosed for any other purposes.)
Sex: F ____ M ____
1) Racial / Ethnic Identity & Heritage:
American Indian or Native American
Asian or Pacific Islander
Bi-Racial / Multi-Racial (please specify)
Black / African American
Latino (a) / Hispanic / Chicano (a)
Middle Eastern or Arab
White / Caucasian / European American
Other (please specify) ______
2) Religious Affiliation
Agnostic
Atheism
Baha'i
Buddhism
Christian
Denomination:
______
Hinduism
Islam
Judaism
Native American
Nonreligious Secular
Sikhism
Spiritualism
Taoism
Other______
Name of Church/House of Worship (if any) ______
Please check any certifications that you may have (please specify and include expiration date):
First Aid / CPR ______Other______
Please list any skills that you can share at ANYTOWN (feel free to attach additional information)
Art
Campfire Set-up
Music / Performing Arts (specify)
______
Hiking
Sports (specify)
______
Musical Instrument(specify)
______
Organizational Ability
Photography
Writing
Languages Spoken
______
Other (specify)
______
______
New Counselor Applicants Only: Please give the name, address and phone number of at least one individual (not a relative) who has known you for one year or more.
Name #1 ______Phone number ______
Address ______
Relationship ______
Name #2 ______Phone number ______
Address ______
Relationship ______
Essay Question
On a separate sheet of paper, please thoughtfully answer the following question that pertains to you.Typed responses are highly preferred.
New Applicants: Based on your experience, please write an essay that responds to the following prompt:
“Before ANYTOWN I ...... After ANYTOWN I . . . . .”
In your essay, you may also discuss your involvement in the community since ANYTOWN.
Experienced Counselors: Please write an essay that discusses a memorable moment/event from the most recent time that you were on staff as an ANYTOWN Counselor. Describe this moment or event and explain how it impacted you.
Commitment:
I understand that if chosen as staff for ANYTOWN 2015, I must attend staff training as well as ALL days of ANYTOWN. All training dates are mandatory. If you cannot commit to the training dates, please do not submit your application. Training sessions are to ensure that ANYTOWN will be the best ANYTOWN for the 2015 delegates; without adequate training we are unable to provide that experience.
Training Dates:
New Staff Orientation: (for Session I & II new counselors only): Tuesday, June 2nd, 6-9 pm
At NCCJ
Session I Staff Training Dates:
Counselors Only-Monday, June 9th, 6-9 pm At NCCJ
All Staff-Tuesday, June 16th, 6-9pm At NCCJ
Leave for BRCC Saturday, June 20th
Session II Staff Training Dates:
Counselors Only-Wednesday, July 9th, 6-9 pm At NCCJ
All Staff-Monday, July 14th, 6-9pm At NCCJ
Leave for BRCC Saturday, July 18th
Disclosure:
By signing below, you consent to a criminal background check(s) and to provide any paperwork required to complete the I-9 Form as required for all NCCJ residential program staff and volunteers.
Applicant Signature:______Date:______
Social Security Number: ______
Parent/Guardian Signature:
By signing below, I give my permission for the young person named above to apply as a Counselor for the NCCJ of the Piedmont Triad ANYTOWN 2015 residential program.
Parent/Guardian:______Date: ______ (if applicant is under 18)
Selected applicants will be contacted to schedule an interview with a member of the NCCJ Program Staff. If geographic location prevents an applicant from coming to our office, the Program Department will schedule a phone interview.
MAIL, FAX OR DROP OFF YOUR APPLICATION TO:
NCCJ ANYTOWN Counselor Application
NCCJ of the Piedmont Triad, Inc.
713 North Greene Street
Greensboro, NC 27401
Fax: (336) 272-1814
If you have questions, please call (336) 272-0359.
Applications are due in the NCCJ office no later than 5:00 pm on Monday, March 21, 2015.
Staff selectionnotification will be made by mid-April.