Girl Scouts of Northern New Jersey
Attn: Elena Morgan
1579 Sussex Turnpike
Randolph, NJ 07869
973-248-8200
2017 LAKE RICKABEAR DAY CAMP STAFF APPLICATION
APPLICANT INFORMATION
Last Name
First Name
Date Of Application
Permanent Address
Email
Current occupation or year in school
Cell Phone
Home phone
Where did you learn
about this position?
(if staff, who?)
Have you ever worked
for this company?
Dates available to work
(camp runs 7/3-8/18)
NO ☐
YES ☐
If so, when and where?
POSITION DESIRED
Indicate ANY positions that you would like to be considered for
☐ Assistant Director
☐ Jr Counselor (16+ CIT 1 and 2)
Additional Positions (extra pay)
☐ Program Director
☐ Environmental Education Specialist
☐ Bus Chaperone
Bus #
☐ Health Supervisor
☐ Archery Specialist
☐ Substitute Bus
Counselor
Bus #
☐ Business Manager
☐ Arts and Crafts Specialist
☐ Lead AM Care Counselor
☐ Kitchen/Trading Post
Manager
☐ Team Building Specialist (certification
provided)
☐ Lead PM Care Counselor
☐ Kitchen Assistant (16+)
☐ Waterfront Director
☐ AM Care Counselor
☐ Head Unit Leader
☐ Assistant Waterfront Director
☐ PM Care Counselor
☐ Unit Leader
☐ Lifeguard (certification provided)
☐ Day and Away Counselor
☐ Assistant Unit Leader
☐ Jr Lifeguard (certification provided, 16+)
EDUCATION
Name of School
Dates
Degree or Field Of Study
TRAINING AND SKILLS
First Aid, CPR, Lifeguard, Boating, Archery, Challenge Course, etc.
Certification
Agency
Date of Course
TRANSPORTATION
☐ I would prefer to ride the bus (Seats are not guaranteed. Campers get first priority.
☐ I will drive my own vehicle or carpool
Bus #
Expiration Date
AGE VERIFICATION
In order to provide quality care and meet legal requirements for supervision of children, please indicate:
☐ I will be under 18 years old during summer 2017 (you must have completed CIT 1 and 2)
In order to
☐ I will turn 18 during summer 2017 (birthday July 3rd-August 18th)
☐ I will be 18 or older during summer 2017
REFERENCES (NEW STAFF ONLY)
List three persons NOT related to you who can judge your qualifications for this position. Send each person a Reference
Form to complete and return to the Camp Director at the address listed below.
Name
Email
Phone
PREVIOUS EMPLOYMENT (NEW STAFF ONLY)
Company 1
Position
Address
Phone
Period of
employment
Company 2
Position
Address
Phone
Period of
employment
Company 3
Position
Address
Period of
employment
Phone
DISCLAIMER AND SIGNATURE
Do you know of any reason why you would not be able to perform the essential functions of the job position for which you are applying
with or without reasonable accommodation?
☐ NO
☐ YES
If yes, what accommodations might be necessary?
I understand that completion of a health history form is a condition of employment. I certify that all information provided on this
application is true and complete. I am aware that falsification or significant omissions of any information may be considered justification for
dismissal if discovered at a later date. I hereby grant consent to the council to secure a criminal background check. (note: refusal to
grant permission voids this application.)
Signature (must be ink
signature, not typed)
Date:
Parent/Guardian Signature
(If Applicant Is A Minor):
Date:
Please return this completed application to:
Girl Scouts of Northern New Jersey
Attn: Elena Morgan
1579 Sussex Turnpike
Randolph, NJ 07869
Fax: 973-927-7683
Email: [email protected] (must be scan with signature)