Sydney
Melbourne
Brisbane
Level 8, Suite 811, 301 George Street, Sydney, NSW 2000
Level 1, 366 Lygon Street, Carlton, VIC, 3053
PO Box 1220, Toombul QLD 4012
Camp Counselors USA Pty. Ltd
Phone (02) 9262 2802
Phone (03) 9347 5800
Phone 0400 026 292
[email protected]
[email protected]
[email protected]
ACN 054 266 518
ABN 85 054 266 518
Thanks for taking the first step towards an amazing working adventure!
Following you will find the documents to complete your application for CCUSA’s “Camp Counselors Russia” Program.
The application process is simple! Just follow the instructions below.
Application Documents
Complete all of the attached and return to CCUSA.
1. Read & Sign the Program Agreement
2. Complete the Program Application & Addendum.
3. 2 x Passport Sized Photo’s
4. 2 x CCUSA Reference Questionnaire Forms
5. Payment of at least AU$100
6. Copy of your Passport (photo page)
7. Email confirmation that you have applied for your Australian Federal Police Check (Code 28) using the instructions
included in this PDF.
Application Deadline
Applications close March 1st.
Program Payment
Payments can be made by cheque or money order (to CCUSA), or by credit card over the phone or by completing the
below credit card authorization form and sending it in with your other documents.
Please send your application and payment to:
CCUSA
Level 8, Suite 811
301 George Street
Sydney, NSW 2000
We look forward to receiving your application!
The Team at CCUSA
If paying by credit card call CCUSA on (02) 9262 2802 or complete the form below
Please debit my (tick appropriate box) VISA
MASTERCARD
Card Number: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Date of Expiry: _____ /_____
Name on the Card:_______________________________________ Signature: _________________________________
Name of Participant: _________________________________________________________________________________
www.ccusa.com.au
CCUSA Program Application
OFFICE USE ONLY
Position: ________________________
Staff Category:___________________
Employment Confirmation:________________
Pocket Money $: _________________
Dates: _________________________________
Program Code: _________________________
CCUSA Fee $:___________________
Include 2 smiling
passport size photos
Use a paperclip to attach
photos:
do not GLUE to
ap­pli­ca­tion
Employers will review your application thoroughly to determine eligibility for placement. Complete all
sections neatly in BLACK ink or type or apply online at http://applications.ccusa.com for faster
application processing. Use only the English alphabet.
Program Applying for: (Check only one program unless you are applying for a combination program)
Camp Counselors USA
Camp Counselors Russia
Work Exchange UK
Work Experience USA
Camp Counselors Canada
Work in English Pubs
P E R S ON A L
Dates of Availability: (be specific)
Note: Not all programs are available in all countries.
Practical Training USA
Volunteer Experience Africa
Volunteer Experience Asia
Work & Play Canada
Volunteer Experience Latin America
Work Adventures Down Under
Other ______________________________________________________________________________________
Date you can depart your home country
IN F O R M A TION
_________________________
DAY
MONTH
Date you must return to your home country_________________________
YEAR
DAY
MONTH
YEAR
Enter all information exactly as it appears on your passport
Family Name
Male
Female
Middle
First
Date of Birth______________________________ City/Town of Birth___________________________ Country of Birth__________________________________
DAY
MONTH
YEAR
Citizen of____________________________ Permanent Resident of________________________________ Present Occupation_________________________
COUNTRY
COUNTRY
Name of School/Employer: ___________________________________________________________ Do you have dual citizenship or passports?
YES
NO
If yes, which passport will you use for your visa?____________________________________________ Passport Number_________________________________
Passport Issue Place ______________________ Passport Issue Date ___________________________ Passport Expiry Date ______________________________
Have you or either of your parents ever held US Citizenship or a US Passport?
Weight ____________ kgs
Height _____________ cms
YES
NO
YES
Do you have a Driver’s License?
Permanent postal address to be reached at all times:
NO
YES
Do you have internet access?
T-shirt Size
S
NO
M
L
XL
Number/Street
City/Suburb
State/County
Postal Code
Country
Email _________________________________________________________________ How often do you check email? _______________________________________
(
)(
)
(
)(
)
(
)(
)
Phone ______________________________________
Mobile Phone __________________________________
Work Phone __________________________________
COUNTRY CODE / CITY CODE
COUNTRY CODE / CITY CODE
Are you married?
YES
NO
Are you engaged to be married?
COUNTRY CODE / CITY CODE
YES
NO
Do you have children?
YES
NO
)(
)
Emergency Contact: Name__________________________________________ Relationship ____________________ Telephone __(____________________________
COUNTRY CODE / CITY CODE
Do you have friends/relatives in the country you are travelling to?
YES
NO
If YES, does this person speak English?
YES
NO
(
)(
)
Name_____________________________________________________________ Relationship ____________________ Telephone _______________________________
COUNTRY CODE / CITY CODE
E D U C A TION
Are you a full-time student? If yes, check category:
Circle Current Year in Education:
UNIVERSITY
University Undergraduate
1
2
3
4
Graduate Student
POST GRADUATE
5
6
7
Professional/College/Technical/TAFE
8
Medical School
OTHER________________________________
List secondary school you have attended:__________________________________ Dates of attendance ______________ Did you complete?
1
2
YES
3
4
NO
List colleges or universities you have attended (or are attending):
Name of College/University
Date started
Estimated Graduation Date
Major course of study
_______________________________________________
_____________________
____________________
________________________________
_______________________________________________
_____________________
____________________
________________________________
Career plans_________________________________________________________________ Languages spoken fluently _____________________________________
If English is your second language, how long have you been studying it?_________________________________________________________________________
WORK
Describe your most recent jobs (paid or voluntary positions)
H I S TO R Y
Reason for leaving?
__________________________________________________________________
___________________________________________________________________
__________________________________________________________________
___________________________________________________________________
__________________________________________________________________
___________________________________________________________________
Rev.16.02.12
M E DIC A L
H I S TO R Y
YES
NO
Are you in good health? If no, explain_______________________________________________________________________________________
YES
NO
Any physical disabilities (past or present)? If yes, explain______________________________________________________________________
YES
NO
Do you suffer from any pre-existing medical conditions? If yes, provide separate description.
YES
NO
Any allergies? If yes, specify_______________________________________________________________________________________________
YES
NO
Are you a vegetarian or vegan? If yes, check which
YES
NO
Any special dietary needs? ________________________________ (special dietary needs cannot always be accommodated)
YES
NO
Do you consume alcoholic beverages? If yes:
YES
NO
Do you smoke? If yes, how often? _________________________________________________________________________________________
YES
NO
Most employers have smoke free environments. Are you prepared not to smoke while at work?
YES
NO
Are you presently or have been, in the last two years, on any medication? If yes, explain_________________________________________
YES
NO
Have you ever suffered from a nervous breakdown, depression or other emotional disorder? If yes, provide separate de­scrip­tion.
YES
NO
Are you currently or have you ever received psychiatric care? If yes, provide separate description.
YES
NO
Have you ever suffered from an eating disorder? If yes, provide separate description.
Daily
Vegetarian
Vegan
 Every 2 weeks
 Weekly
 On special occasions
YES
NO
Have you ever had a drug addiction/problem? If yes, provide separate description.
YES
NO
Do you have any visible tattoos or body piercing? If yes, describe._____________________________________________________________
YES
NO
Are you willing to cover your tattoos and cover or remove your body piercing? If no, explain _____________________________________
YOUR
P E R S ON A L IT Y
&
INT E R E S T S
Do you prefer to work alone or with a group? Why?____________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
Why do you want to participate in this program?_______________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
What do you think will be your greatest challenge in working overseas and why?__________________________________________________________________
__________________________________________________________________________________________________________________________________________
Why should an employer choose you as a participant?__________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
Tell us about your interests, hobbies or activities.________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
B A C K G R O U ND
CHECK
Have you ever been arrested or convicted of a criminal offense or are you at present, the subject of a criminal investigation?
(If YES, a detailed ex­pla­na­tion must be enclosed on a separate piece of paper)
YES
NO
YES
NO
Have you ever been charged with or convicted of sexual abuse or molestation?
Note: A criminal police background check may be required for some programs and/or required by the consulate when applying for your visa. Further
information will be given to you if you apply to these specific programs.
P R E V IO U S
VISAS
Please list any visas you have held in the past. Do not include the visa you will be applying for on this program.
Country
Visa Name or Type
Working Visa?
Year
Sponsor Agency
Employer Name
_______________________ ________________________
YES
NO
______________ ________________________ ____________________________
_______________________ ________________________
YES
NO
______________ ________________________ ____________________________
_______________________ ________________________
YES
NO
______________ ________________________ ____________________________
Total number of USA J1 Visas Held : __________
Attach a separate sheet if necessary.
RETURNEE
IN F O R M A TION
Have you participated on this program or a similar program with a different agency before?
YES
NO
If Yes, Employer / Camp Name: ________________________________________________________ Position:_______________________________________________
Are you applying to return to your Employer / Camp?
to return.
YES
NO If Yes, please include an invitation from your previous Employer / Camp inviting you
Camp Counselors Russia Addendum
Complete all sections neatly in BLACK ink or type. Use only the English alphabet.
Applicant Name ______________________________________________________________________
CCUSA ID #
Choose Program Length:
1st 4 week program and 8 week program: Arrive in Moscow on June 17th
2nd 4 week program: Arrive in Moscow on July 15th
Do you wish to travel independently after camp?
Are you willing to teach English?
Yes
Yes
No All visas will be valid until September 1st and cannot be extended past this date.
No Are you applying with a friend?
Yes
No If yes, name _______________________________________
SKILLS
List every skill, hobby or sports activity in which you have experience, then rate each skill in two areas: PE = Personal Experience and TA = Teaching
Ability. We need an honest evaluation – do not underrate or overrate your abilities!
PE = Personal Experience (10=Excellent, 9=Good, 8=Fair)
TA = Teaching Ability (10=Expert level, 9=Strong level, 8=Limited level, 7=No experience)
SPORTS
PE
ARTS & CRAFTS
PE
TA
TA
WATERFRONT
PE
TA
OUTDOOR SKILLS
PERFORMING ARTS
PE
TA
SCIENCE & OTHER
PE
TA
PE
TA
Select from the skills/positions you listed above
List the top three skills that you are capable of and willing to instruct at camp. Describe in detail all personal and teaching experience you have in
connection with these skills, including the length of time involved with the skill and how old you were at the time.
SKILL 1 ___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
SKILL 2 ___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
SKILL 3 ___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________
Q U A L I F I C AT I O N S / C E RT I F I C AT I O N S
Check only if you have current certifications in the following and indicate expiration date where applicable. Enclose copies of these certificate
American Red Cross Lifeguard (ARC) Austswim (qualified swim instructor) Bronze Medallion - lifeguard
CPR/First Aid NPLQ (National Pool Lifeguard Qualification) Pony Club
School Teacher Ski Boat License Water Safety Instructor (WSI)
Rev.09.11.15
LEADERSHIP EXPERIENCE
Describe all leadership/volunteer positions you have held_______________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
Were you a Boy Scout, Girl Guide, or Scout Leader?
Have you previously worked at a camp?
YES
YES
NO
NO
If yes, when and for how long?_____________________________________________
If yes, number of years you have worked at camp. _______________________________________
Which camp?_____________________________________________________________________ When?__________________________________________________
EXPERIENCE WITH CHILDREN
Describe the most recent and relevant experiences you have had with children. List children’s ages, your responsibilities and years involved. (Use a
separate sheet if necessary)._________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
Which age groups have you had prior work experience with? Check all that apply. (Cabin counselors live with ap­prox­im
­ ate­ly 5-10 campers grouped by
5-7 years
8-10 years
11-12 years
13-15 years
16-17 years
Adults
age and grade in school.)
Be sure to complete this section on a separate sheet of paper. It should be a full-sized sheet of paper. Write neatly in black ink or type (with a 2 cm
border of white space)
A U T O B I O G R A P H I C A L E S S AY
Tell us about your family, interests, activities, hobbies, and other experiences which will make you a good counselor on the CCUSA program. Camp
Directors enjoy reading your essays, so use this opportunity to present an accurate and interesting story of your life.
F O R E I G N L A N G U A G E E S S AY
If you have experience with a foreign language, on a separate piece of paper, please write a short essay in that language about what intrigues you most
about participating in this program. This should be a true representation of your language interest.
A D D I T I O N A L V I S A I N F O R M AT I O N
Current Employer Address __________________________________________________________________________________________________________________
Current University/school Address ___________________________________________________________________________________________________________
Please include a copy of your current passport with this addendum
How To Complete
The Reference Ques­tion­naire
Please read before completing the reverse side of this form.
Dear Sir or Madam,
The person named on the reverse side of this form has applied for a position as a counselor on the Camp
Counselors Russia programme. Your honest appraisal of this applicant will assist us in determining if the applicant
is suitable to participate in the camp programme in Russia.
The applicant must possess responsibility, flexibility, a sense of humour and a high level of moral integrity – they
must be able to adapt to a different culture and way of life. Outlined below is a description of the position of a
counselor.
Counselor: As a counselor, the participant will be required to teach, lead and be a friend to a group of children
aged anywhere from five to sixteen. Their primary responsibility is to ensure the children’s safety and wellbeing and to help make the children’s camp experience fun and rewarding. Their tasks usually include planning,
leading and joining in activities. All counselors perform a wide variety of duties with children, and each day brings
something new. Counselors live in tents or dormitories with children and often spend 24 hours a day for four or
eight weeks with them. Although speaking Russian is not an essential part of the programme, it is important the
counselor is willing to learn about Russian culture, and to not be afraid of trying out a few words which the children
will teach them. For non-Russia speaking counselors, they will be paired with a similar aged English-speaking
Russian counselor to work with.
As the referee, you need to make an objective assessment of the character and abilities of the applicant. Any
additional comments, which will help us, determine the suitability of the applicant are appreciated. Your quick
response is encouraged, as we are unable to proceed with the application without your reference. If you wish to
share any reservations about the suitability of this applicant in private, please contact the Camp Counselors Russia
office.
This Reference Questionnaire should be completed by a teacher, coach, tutor, employer, priest, minister or rabbi.
We cannot accept references from family mem­bers, rel­a­tives or friends.
Thank you!
Please return the Reference Questionnaire as soon as possible to the applicant in a sealed envelope.
(Application cannot be processed without your reference).
Use the space below for additional comments:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Camp Counselors Russia Reference Questionnaire
Applicant’s Name___________________________________________ ID#
To be completed by referee after reading the reverse side of this form. Because of the important
respon­si­bil­i­ties in a program involving children, your honest appraisal of the applicant is of the utmost
im­por­tance. The information you provide is appreciated and will remain confidential. Family members
and peers—please do not complete this form.
PERFORMANCE EVALUATION
Please check the items for which you have sufficient knowledge about the applicant:
Excellent
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Very
Good
Good
Fair
Not Ap­pli­ca­ble/
Unable to Answer
Integrity
Work habits/organization
Adaptability/flexibility
Attitude
Relationship with co-workers
Leadership abilities
Ability to work in groups
Responsibility
Ability to relate to children
Children’s response to applicant
Maturity
Perseverance
OBJECTIVE RATING
Under each heading, check the phrase which most accurately describes the applicant:
1. Ability to direct and influence others:
Exceptional leadership qualities
Usually successful in leading others
Unreliable leadership qualities
2. Ability to work and cooperate with others:
Gets along exceptionally in groups—a team player
Will cooperate in most circumstances
Gives limited cooperation—better suited to solitary work
3. Ability to relate to and give guidance to children:
Children naturally get along very well with applicant
Children adequately participate
Children often ignore instruction
5. Ability to control emotions:
Well balanced, good control
Average ability to control emotions
Frequently irritated, impatient, or depressed
7. What is your relationship to this person? Teacher
Coworker
4. Ability to follow through with job assignments:
Completes tasks promptly, often does more than expected
Completes assigned tasks at own pace
Needs constant supervision to complete work
6. How would you rate the applicant as a role model for children:
Excellent
Fair
Very Good
Poor
Coach/coaches my child Tutor/tutors my child
Priest/Minister/Rabbi My child’s babysitter
Supervisor
Employer
8. How long have you known this applicant? __________________________________________________________________________________
9. Would you be willing and completely comfortable leaving your children under the applicant’s supervision? Please explain:
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
10. Does the applicant show signs of any behavior which you feel would cause a concern when working directly with children?
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
11. Please comment on the applicant’s suitability for this program (Use separate piece of paper if necessary):_________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
You may be contacted by CCUSA or a camp for verification of your reference for this participant.
Name of Referee________________________________________Signature____________________________________ Date__________________
(
)(
)
Address_____________________________________________________________________________Phone__________________________________
COUNTRY CODE / CITY CODE
Company________________________________________________________Position/Title________________________________________________
Email____________________________________________________________ Fax _______________________________________________________
Please return this form to applicant in a sealed envelope at your earliest convenience. Thank you for your evaluation!
Rev.20.11.06
How To Complete
The Reference Ques­tion­naire
Please read before completing the reverse side of this form.
Dear Sir or Madam,
The person named on the reverse side of this form has applied for a position as a counselor on the Camp
Counselors Russia programme. Your honest appraisal of this applicant will assist us in determining if the applicant
is suitable to participate in the camp programme in Russia.
The applicant must possess responsibility, flexibility, a sense of humour and a high level of moral integrity – they
must be able to adapt to a different culture and way of life. Outlined below is a description of the position of a
counselor.
Counselor: As a counselor, the participant will be required to teach, lead and be a friend to a group of children
aged anywhere from five to sixteen. Their primary responsibility is to ensure the children’s safety and wellbeing and to help make the children’s camp experience fun and rewarding. Their tasks usually include planning,
leading and joining in activities. All counselors perform a wide variety of duties with children, and each day brings
something new. Counselors live in tents or dormitories with children and often spend 24 hours a day for four or
eight weeks with them. Although speaking Russian is not an essential part of the programme, it is important the
counselor is willing to learn about Russian culture, and to not be afraid of trying out a few words which the children
will teach them. For non-Russia speaking counselors, they will be paired with a similar aged English-speaking
Russian counselor to work with.
As the referee, you need to make an objective assessment of the character and abilities of the applicant. Any
additional comments, which will help us, determine the suitability of the applicant are appreciated. Your quick
response is encouraged, as we are unable to proceed with the application without your reference. If you wish to
share any reservations about the suitability of this applicant in private, please contact the Camp Counselors Russia
office.
This Reference Questionnaire should be completed by a teacher, coach, tutor, employer, priest, minister or rabbi.
We cannot accept references from family mem­bers, rel­a­tives or friends.
Thank you!
Please return the Reference Questionnaire as soon as possible to the applicant in a sealed envelope.
(Application cannot be processed without your reference).
Use the space below for additional comments:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Camp Counselors Russia Reference Questionnaire
Applicant’s Name___________________________________________ ID#
To be completed by referee after reading the reverse side of this form. Because of the important
respon­si­bil­i­ties in a program involving children, your honest appraisal of the applicant is of the utmost
im­por­tance. The information you provide is appreciated and will remain confidential. Family members
and peers—please do not complete this form.
PERFORMANCE EVALUATION
Please check the items for which you have sufficient knowledge about the applicant:
Excellent
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Very
Good
Good
Fair
Not Ap­pli­ca­ble/
Unable to Answer
Integrity
Work habits/organization
Adaptability/flexibility
Attitude
Relationship with co-workers
Leadership abilities
Ability to work in groups
Responsibility
Ability to relate to children
Children’s response to applicant
Maturity
Perseverance
OBJECTIVE RATING
Under each heading, check the phrase which most accurately describes the applicant:
1. Ability to direct and influence others:
Exceptional leadership qualities
Usually successful in leading others
Unreliable leadership qualities
2. Ability to work and cooperate with others:
Gets along exceptionally in groups—a team player
Will cooperate in most circumstances
Gives limited cooperation—better suited to solitary work
3. Ability to relate to and give guidance to children:
Children naturally get along very well with applicant
Children adequately participate
Children often ignore instruction
5. Ability to control emotions:
Well balanced, good control
Average ability to control emotions
Frequently irritated, impatient, or depressed
7. What is your relationship to this person? Teacher
Coworker
4. Ability to follow through with job assignments:
Completes tasks promptly, often does more than expected
Completes assigned tasks at own pace
Needs constant supervision to complete work
6. How would you rate the applicant as a role model for children:
Excellent
Fair
Very Good
Poor
Coach/coaches my child Tutor/tutors my child
Priest/Minister/Rabbi My child’s babysitter
Supervisor
Employer
8. How long have you known this applicant? __________________________________________________________________________________
9. Would you be willing and completely comfortable leaving your children under the applicant’s supervision? Please explain:
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
10. Does the applicant show signs of any behavior which you feel would cause a concern when working directly with children?
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
11. Please comment on the applicant’s suitability for this program (Use separate piece of paper if necessary):_________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
You may be contacted by CCUSA or a camp for verification of your reference for this participant.
Name of Referee________________________________________Signature____________________________________ Date__________________
(
)(
)
Address_____________________________________________________________________________Phone__________________________________
COUNTRY CODE / CITY CODE
Company________________________________________________________Position/Title________________________________________________
Email____________________________________________________________ Fax _______________________________________________________
Please return this form to applicant in a sealed envelope at your earliest convenience. Thank you for your evaluation!
Rev.20.11.06
2016 Camp Counselors Russia Program Agreement – Australia
This agreement is between CCUSA Inc., (CCUSA) and
CCUSA ID #
(print name) you, a CCUSA participant
Acceptance and Placement at a Camp
1. To apply to the Camp Counselors Russia Program you will be required to pay program fees (all payments should be made
out to CCUSA):
a. An application fee of AU$100.00 must accompany your application. Once accepted to the program you will be required
to pay one of the below program fees:
•
4 week program fee with economy insurance: AU$1,595
•
4 week program fee with premium insurance: AU$1,660
•
8 week program fee with economy insurance: AU$1,740
•
8 week program fee with premium insurance: AU$1,850
st
b. Applications close March 1 , 2016.
2. An additional surcharge will apply for expedited application and visa processing.
3. CCUSA insurance covers you for 4 weeks or 8 weeks, depending on the program you choose. Insurance begins the day
before you are due to arrive in Moscow and includes: accident and sickness, trip interruption, medical evacuation (see
Insurance brochure for full details on the policy). Insurance does not cover pre-existing conditions or car insurance.
CCUSA is not the insurance company. It is your responsibility to read and understand the insurance policy details (including
the Financial Services Guide & Product Disclosure Statement) including what coverage does and doesn’t cover (eg. It does
not cover pre-existing medical conditions and auto insurance). If you require specific insurance coverage that is not
available on this policy you will need to locate and purchase this on your own. In case of an accident or incident it is your
responsibility to submit a claim form with all original documentation and/or follow the procedures set out by the insurance
company. Full details of the insurance policy (which includes the Financial Services Guide & Product Disclosure Statement)
can be found on the website http://www.ccusa.comau/MoreInformation/Insurance.aspx or by contacting CCUSA.
4. If you are traveling longer than 4 or 8 weeks, you will need to extend your travel insurance before departure. Extensions
after departure at the discretion of the insurance company.
a. Extensions for Economy Insurance coverage are AU$4.50/day before departure.
b. Extensions for Premium Insurance coverage are AU$6.25/day before departure.
5. Your application form and references are legal documents. You agree that you have personally completed the application form
and any false, misleading or withheld information on your application or inappropriate behavior during your interview, on social
media sites, prior to departure from Russia or during your participation on the CCUSA program, is grounds for immediate
cancellation from the program without refund. You are required to inform CCUSA of any changes in information provided
within your initial application, including but not limited to: health conditions, availability dates, skills and contact details.
6. While participating on the CCUSA program you are required to check and provide CCUSA with a current email address that
you will access at least twice a week from the time of application through the time you complete your trip to Russia. CCUSA
will not be held responsible for problems arising from failure to check your email regularly (including junk mail) or failure to
notify CCUSA of changes to your email address. You may not use a university or school email account. You are required to
create a personal web-based email account once you are accepted to the CCUSA program.
7. Upon acceptance, your application will be sent to Moscow. Placement at a camp occurs on an ongoing basis. CCUSA will
notify you as soon as your placement with a camp is finalized. Due to Camp Directors making final staffing decisions,
placement is not guaranteed.
8. CCUSA will provide you with visa documents and instructions n order to apply for this. The cost of regular visa processing
(10 days) is included in your program fees and we will lodge the visa application on your behalf at the Russian Consulate in
Sydney. If you require your visa to be expedited or you require a visa above and beyond what’s needed for this program,
you will be responsible for the extra visa costs. CCUSA aims to apply for all visas in the second week of May. The visa
permits you to enter Russia to participate in the CCUSA program. You cannot participate in the program without this visa.
You are required to submit a photocopy of your passport at the interview, which is used to generate a visa invitation telex
from Moscow. CCUSA will also need your original passport to apply for this visa at the beginning of May, so we can lodge
2016 Camp Counselors Russia Program Agreement – Australia
This agreement is between CCUSA Inc., (CCUSA) and
CCUSA ID #
(print name) you, a CCUSA participant
your visa application at the Russian Consulate.
CCUSA has two scheduled arrival dates in Moscow, June 17, 2016 for the first 4 week program and the 8 week program
and July 15, 2016 for the second 4 week program.
10. The date on which camp ends is included with your camp placement information. You must work at camp until this date.
11. You, the applicant, are the only person CCUSA will liaise with in terms of your application/placement. CCUSA will not
provide information about your application or program participation to parents/friends/other family, unless you are involved
in a medical emergency while in the Russia, in which case we will contact the person you have listed on your CCUSA
application form as your “emergency contact.”
12. You are required to send an introduction letter, postcard or email to your camp director upon receiving your placement
information.
9.
Criminal Background Check and Health History Form
1. As part of the application you are required to disclose to CCUSA any and all past or current medical conditions (if you
are unsure of what to include contact CCUSA to discuss).
2. If accepted, you must download the CCUSA Health History form, which must be completed and signed by your physician. This
must be completed per the instructions and submitted to CCUSA at least 4 weeks prior to departure for Russia. Failure to
complete the Health History Form is grounds for dismissal from the program without a refund.
3. As part of the application you are required to disclose to CCUSA any and all criminal history, criminal offense, arrests,
charges, or sentencing. Failure to complete the FBI Background Check will result in dismissal from the program without a
refund. You must get a Federal Police Background Check, using the instructions CCUSA provides you. This is the only
Police Check CCUSA can accept. You must follow the instructions including forwarding a copy of the email you have sent
to the Federal Police showing the completed Consent form, 100 points of ID and payment receipt within 14 days of paying
at least your application fee. You must also use the CCUSA address for the return of your Federal Police Background
Check. If you receive this check directly you must forward it to CCUSA immediately, in both cases CCUSA will forward this
to your camp. If you are not a citizen or permanent resident of Australia, you must also gain a criminal/police background
check from your home country. Any criminal history reflected in this background check (regardless of what you have stated
on your CCUSA application form) could affect your acceptance/placement and result in cancellation from the program and
loss of fees paid to CCUSA.
Refund Policy
1. The application fee of AU$100 is refundable only if you are not accepted to the program.
2. The program fee will not be refunded if you cancel from the CCUSA program, except in the case of your serious illness
(doctor’s verification required within 10 days of cancellation) or serious illness or death of a parent or sibling (doctor’s
verification required within 10 days of cancellation). If this occurs, CCUSA will refund a portion of your fees less any costs
incurred to date. All cancellations must be submitted in writing.
4. If you are not placed by June 1, 2016 you will be cancelled from the program and receive a full refund of the fees paid to
CCUSA, less the application fee. In this event, refunding the fees is the limit of CCUSA’s responsibility, as damages for
non-participation are impossible to calculate.
Travel to Camp
1. You must arrange and pay for your own transportation and return flight to and from the designated CCUSA Moscow airport.
2. CCUSA and our partner, Artek Tour will provide accommodations, most meals and tours in Moscow while you are
attending the arrival orientation.
3. Once in Moscow, Artek Tour will provide round-trip transportation to and from your camp. This typically is a multiple day
train journey.
2016 Camp Counselors Russia Program Agreement – Australia
This agreement is between CCUSA Inc., (CCUSA) and
CCUSA ID #
(print name) you, a CCUSA participant
During the Summer
1. The standard resident camp season consists of either a four or eight-week period with a certain number of days off, which
are decided upon by the Camp Director. The amount of the small stipend you receive in Russia, is determined by your
Camp Director according to camp policy, but will typically be no more than 1000 rubles per month (US$15).
2. The camp provides you with room, board, and bedding free of charge during the camp session. Your personal expenses
before, during and after camp are your own responsibility.
3. Your visa is typically valid until September 1st, 2016 and cannot be extended. You are responsible for making any and all
arrangements for independent travel around Russia after your camp has finished.
Early Departures
1. If you fail to fulfill the responsibilities of your position at camp or violate any camp rules, your participation will be terminated.
The camp director has full discretion over employment and termination decisions. In case of termination or voluntary early
departures from camp the following penalties will result: forfeiture of all fees paid to CCUSA; financial liability for all travel
costs including domestic cost of transportation paid by CCUSA for your travel to camp and the cost of your domestic travel
back to Moscow; financial liability for cost of accommodation in Moscow while waiting for flight and flight “change of date”
penalties. The foregoing does not apply in cases of documented critical illness of you or an immediate family member
(parent or sibling).
I fully understand that I give up a great deal of privacy and comfort, work long and demanding hours and must adhere to camp
policies which may be limiting and not necessarily reflect my way of living (curfews, time on/off, no smoking, no alcohol, etc.).
My signature below confirms that I have read, understood and agreed to abide by the terms, conditions and rules as detailed
above. It also allows CCUSA to forward my name to a preferred travel agent, to our counselors who may wish to share a room
for any travel options and to counselors traveling to the same camp or traveling on the same flight. I allow photos and video
taken of me at meetings, arrival sites and/or at my camp location, or photos and videos I supply to CCUSA, to be used for
publicity purposes. California law applies to any disputes arising out of this agreement.
_______________________________________________
_________________________________
____/____/_____
Name
Signature
Date
_______________________________________________
_________________________________
____/____/_____
Name
Signature
Date
Please make a copy of this for your own records, and return the signed original to:
[email protected]
CCUSA Suite 811, Level 8, 301 George St. Sydney, NSW 2000 Australia Australian Federal Police Che
eck - Nu
umber 28 - Care
e, instruc
ction or
superv
vision of children - Instru
uctions
P
Please
fo
ollow the
ese instrructionss exactly
y!
OR
view
w the helpful Video we ha
ave put togetther https://w
www.facebook.com/ccusaa.australia/vid
deos
As a participan
nt on the Ca
amp Counselors USA, C
Camp Coun
nselors Cana
ada, Camp
p Counselors Russia or
Cam
mp California (in Croattia) program
ms you need
d to obtain a Federal Police
P
Chec
ck. Below are the
instrructions for how to do this
t (it is an online
o
proc ess). Please
e follow thesse instructio ns exactly. No other po
olice
che
eck will be a
accepted so
o make sure
e you apply
y for the Ausstralian Federal Police c
umber 28 check – Nu
Care, instructio
on or superv
vision of chilldren (note Section B, iii. below). Yo
ou should sttart this proc
cess
mediately ass the result of
o this check is part of tthe acceptance proce
ess to the prrogram.
imm
1. Go to: h
https://afpn
nationalpolicechecks.c
converga.co
om.au/
2. On this page ‘tick’ the box to say you ha ve read the
e instruction
ns and then press the ‘S
Start Online
ation’ button
Applica
3. You will then need to proceed
d through th
he questions and make
e sure you a
are completting them with
w
care. Th
here are som
me specific answers yo
ou need to give
g
for som
me question
ns (the otherrs are selfexplana
atory):
Section B: ‘Purpose of Check’
i.
P
Purpose
Type
e: ‘Commo
onwealth pu
urpose/Emp
ployment’
ii.
P
Purpose
of Check:
C
ONLY
Y CHOOSE Police Chec
ck ’Numberr 28 - Care, instruction or
o
supervision of
o children’
ed’
Section C: ‘Type of Check Require
Name check only’
i.
‘N
Section H: ‘Mailing
‘
Add
dress of the
e Certificate
e’
i.
Un
ntick the bo
ox (the chec
ck needs to be returned
d to CCUSA
A not you!)
ii.
Atttention to: ‘CCUSA
iii.
Un
nit No/Stree
et No/Street Name: ‘Lev
vel 8, Suite 811,
8
301 Ge
eorge Streett’
iv.
Su
uburb/Town
n/Locality: ‘SSydney’
v.
State: ‘NSW’
vi.
Po
ostcode: ‘20
000’
vii.
Country: ‘Ausstralia’
4. Proceed
d and confirm your details.
5. You will then be assked to fill out a consen
nt form that you will need to print a
and sign to give conse
ent
check to be
e done. You
u will need tto scan this signed doc
cument, alo
ong with a sc
canned copy
for the c
(prefera
ably in PDF format)
f
of your
y
photo IID (Drivers Licence or Passport)
P
into
o your application. No
ote,
the con
nsent form will
w tell you what
w
docum
ments will giive you the required 1000 points of ID.
6. Make p
payment of AU$42 on th
he paymen
nt screen usiing Visa, Ma
astercard orr American Express. On
nly
press ‘P
Pay Now’ on
nce.
7. CCUSA need to know that you
u have appllied for this check. Afte
er your chec
ck has been
n submitted
d,
you willl receive an
n email from
m the AFP tha
d your paym
ment receip
pt
anking you for the submission and
will be a
attached. Please forwa
ard this ema
ail to [email protected]
com.au.
p the Prog
gram Agree
ement, failurre to show p
proof to CC
CUSA that yo
ou have ap plied and paid
p
for this
As per
police check w
within 14 day
ys of making
g your prog
gram applic
cation paym
ment will resu
ult in you be
eing charge
ed a
charge of AU$75.
surc
If yo
ou are expe
eriencing an
ny problemss with this ap
pplication, please
p
conttact us for a
assistance. Again,
A
this iss
the only police check we will accept.
Thank you
CCU
USA Australiia / Australia
[email protected]
om.au / 130
00859040