New Facilitator Application

For students seeking new involvement

with Leadership Camp

Applicant Information (Please provide information current as of the time of application)

Name / Campus ID
University Address / Email Address
Permanent Address Line 1 / Cell Number
Permanent Address Line 2 / Year attended Camp,
if applicable
City / State / ZIP

Academic Information (Please provide information current as of the time of application)

Major / Minor
Credit Hours Earned / Credit Hours Remaining / Semesters Remaining at CMU / Cumulative GPA

Reference Information (Please provide at least two CMU-affiliated persons that Leadership Camp may contact)

Name / Position / Phone / Email
Name / Position / Phone / Email
Name / Position / Phone / Email

Applicant Questions(Please answer the following questions on a separate document and attach to application)

  1. What is your definition of “leadership?” What is your definition of “social change?”
  2. What do you think new students might gain from attending Leadership Camp?
  3. What do you think you might gain from working with Leadership Camp?
  4. What do you think CMU gains from hosting Leadership Camp?
  5. Share one lesson you have learned from your time here at CMU and why you think it is important.
  • Please be reminded that you must be available and participate in ALL training sessions. (Only direct academic conflicts will be excused.) Trainings will be held on Friday, March 24: 4-8pm; Friday, April 7: 4-8pm; Friday, April 21: 4-8pm; and Friday, April 28: 4-8pm; May 8-12 All Day.
  • Please attach (1) a list of your extracurricular activities with dates of involvement and (2) a copy of your Spring 2017 class /commitment schedule.

/CERTIFICATION:

Applicant Signature:Date:

EMPLOYMENT & LEADERSHIP/VOLUNTEER VERIFICATION FORM

(to be completed after a Contingent Offer of Employment or Leadership Position has been made/accepted)

VERIFICATION OF INFORMATION:

I certify that all information provided on any employment application form, resume, or vita is complete, true and accurate to the best of my knowledge. I also understand that information may be verified and any misrepresentation of facts may be considered cause for dismissal regardless of when discovered by the University.

CRIMINAL HISTORY CHECK:

Have you ever been convicted of a felony or misdemeanor? Yes No

Are there any felony charges pending against you?  Yes No

If yes, list date(s), type of offense(s), circumstances, county where conviction occurred and action taken:
______

______

Conviction of a crime will not necessarily render you ineligible for a position(or to volunteer), but the nature of the conviction, circumstances and/or time of the occurrence may be considered in processing your application. Criminal conviction will be considered in relation to the position for which you have applied.

I understand that if I am hired/selected, I may be discharged for any misrepresentation or omission in the above stated information. I also understand that any job offer or subsequent employment may be conditioned on the University’s receipt of a satisfactory Criminal Conviction Report. If determined necessary by the University, I authorize a background check with respect to criminal convictions. If a third party agency is used to conduct a criminal history check, the University agrees to comply with the Fair Credit Reporting Act (FCRA).

OTHER BACKGOUND INFORAMTION:

Have you ever been sanctioned by the CMU Office of Student Rights and Responsibilitiesorany other institution for a disciplinary incident?  Yes  No

If yes, list dates, violations, sanctions, and institution(s):

REFERENCE CHECK:

In accordance with policy and practice the University may inquire and verify any information contained on the application, resume and/or vita as part of the application process. I understand that my current and former employers may release any information contained in my personnel file or otherwise known by them to Central Michigan University in connection with my application for employment with Central Michigan University. I specifically release from liability any current or former employers, their agents, representatives, employees, officers, or directors, for giving such information to Central Michigan University.

"CMU, an AA/EO institution, is strongly and actively committed to increasing diversity and providing equal opportunity within its community. CMU does not discriminate in employment against persons based on age, color, disability, gender, familial status, height, marital status, national origin, political persuasion, race, religion, sexual orientation, veteran status, or weight (see

The information requested is needed to help the University assess your employment qualifications. Michigan law requires that a person with a disability or handicap requiring accommodation to perform the essential duties of the job must notify the employer in writing within 182 days from the date that the need is known or should have been known.

Signature (First, Middle, Last) Print (First, Middle, Last) Date

Department Date of Birth Campus ID #

Have you ever lived or worked outside of Michigan? Yes ___ No___ If no, If YES, please provide State(s)

If YES, Current Address; SSN

If this form contains a Social Security Number, it MUST BE HAND-DELIVEREDto Employment Services, Rowe 109. Rev: 5/2015