OFFICE USE ONLY
Interview Date:_______________________
Starting Pay: ________________________
ANTIETAM RECREATION
Comments: _________________________
________________________________
________________________________
9745 Garis Shop Road, Hagerstown, MD 21740
Phone: 301-797-7999 | Fax: 301-797-7782
[email protected]
www.antietamrecreation.com
PLEASE ATTACH A CURRENT PHOTO
PERSONAL INFORMATION:
Please Print Clearly 1. Full Legal Name:  Mr.  Mrs.  Miss  _____ _____________________________________________________________
OTHER
FIRST
MI
LAST
SUFFIX
NAME YOU GO BY
2. Address: ________________________________________________________________________________________________
ADDRESS
Contact Info: (_______) _______________
CITY
_______________________________________
WORK OR CELL PHONE
EMAIL ADDRESS
3. Birth Date: month ______ / day ______/ year ________
 Engaged
5. Do you have children?
 Married
 Yes
 No
Age _________
 Widowed
 Male  Female T-Shirt Size: _____________
 Separated
 Divorced
If yes, give children’s names and ages ______________________________________
Would you like your children to accompany you to work?
EDUCATION:
ZIP
(_______) _______________
HOME PHONE
4.  Single
STATE
 Yes
 No
High School & College
School Attended
Major/Minor
Years
Degree
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
CAMP EXPERIENCE:
Camp
Camper or Staff?
Director’s Name
Address
Year
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
If camper at Antietam Recreation, specify level achieved: _________ _________ _________ _________
SWIMMING
RIDING
CANOEING
KAYAKING
_________
TENNIS
1
EMERGENCY CONTACT:
Emergency Contact: ___________________________ Phone: (_____)_____-________ Alternate Phone: (_____)_____-________
Relationship:__________________________________
Physician's Name: ______________________________________________________ Physician’s Phone: (_____)_____-_________
Physical Restrictions or Health Problems: __________________________________________________________________________
___________________________________________________________________________________________________________
JOB HISTORY:
Company/Employer: __________________________________ Type of work: ____________________________________________
Address: ____________________________________________ Phone: (_____)______-_______ Hourly Rate /Salary: __________
Reason for leaving: ____________________________________ Dates: From: ______/______/______ To: _____/______/______
Company/Employer: __________________________________ Type of work: ____________________________________________
Address: ___________________________________________ Phone: (_____)______-_______ Hourly Rate /Salary: __________
Reason for leaving: ___________________________________ Dates: From: ______/______/_____ To: _____/______/______
REFERENCES:
List 3 people (not relatives) who have knowledge of your character, ability and experience. Name: ____________________________________________________ Occupation: ________________________________________
Address: _____________________________________________________________________________________________________
Phone#: (______)_______-____________ Relationship: ______________________________________________________________
Name: ____________________________________________________ Occupation: ________________________________________
Address: _____________________________________________________________________________________________________
Phone#: (______)_______-____________ Relationship: ______________________________________________________________
Name: ____________________________________________________ Occupation: ________________________________________
Address: _____________________________________________________________________________________________________
Phone#: (______)_______-____________ Relationship: ______________________________________________________________
OTHER EXPERIENCE:
List any honors, awards, clubs, special activities, or sports.
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
CERTIFICATIONS:
Please indicate which certifications you may hold & their expiration dates. Also list any other certifications you hold, such as tennis,
marksmanship, or riding:
CPR


WSI
(Water Safety Instructor)
Lifeguard
First Aid
EMT



Expiration: ____/____/____
High Ropes
Expiration: ____/____/____
Canoeing
Kayaking
Expiration: ____/____/____
Expiration: ____/____/____
Expiration: ____/____/____




Expiration: ____/____/____
Expiration: ____/____/____
Expiration: ____/____/____
Expiration: ____/____/____
Archery
Other _________________ Expiration: ____/____/____
Nurse (RN, GN, LPN) ____________________________
2
BACKGROUND & CHRISTIAN TESTIMONY:
How do you feel about working at a Christian camp?  Okay
 Hesitant
 Excited
 ____________
Do you attend church?  Yes: Denomination/Association___________________________________________
 No
Have you trusted Jesus Christ as your personal Savior?  Yes  No
If yes, tell how you became a follower of Jesus:______________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
How do you feel about explaining the Gospel to someone?  Very uncomfortable/I decline this responsibility  Nervous/ but I
would like to learn how  Fairly comfortable/ no problem  Very comfortable/ I have lots of experience
Please give three adjectives that best describe your personality: ________________________________________________________
What do you see as your strongest character quality and why? _________________________________________________________
________________________________________________Weakest character quality and why? _____________________________
___________________________________________________________________________________________________________
Do you smoke? _______ Drink alcohol? _______ Have you ever been fingerprinted? _______
What would you like to be doing five years from now? _______________________________________________________________
___________________________________________________________________________________________________________
AUTOBIOGRAPHY: Please write a short autobiography of yourself, including specialized training and experience.
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________ SKILLS & ABILITIES:
The purpose of this section is to determine the general areas you are strongest in, so that it is easy for us to place you in the best position to
utilize your particular strengths. The main classes on our daily Day Camp schedule are listed below. For each part, number the various
activities in order of what you do best. Number 1 indicates your best activity, & the last number indicates your worst activity.
Regular Activities
Optional Activities
Morning Electives
(Number from 1-10)
___ Adventure
(Number from 1-11)
___ Art
___ Baking
___ Crafts
___ Drama/ Theater
___ Dress up
___ Library
___ Story hour
___ Air Soft
___ Dance
___ Manual Labor
___ Antietam has Talent
(Number from 1-13)
___ Archery/ Marksmanship
___ Badminton
___ Cycling (scooters, bikes)
___ Fishing
___ Fitness Swim
___ Forting (in the woods)
___ Gardening
___ Horse Grooming
___ Puppets
___ Roller skating
___ Rope skipping/ Pogo Sticks
___ Synchronized Swim
___ Tumbling or Gymnastics
(games, activities, etc in the woods)
___ Field Sports
(basketball, soccer, football, softball etc)
___ Group Games
(Steal the Bacon, Kick the Can, Dodge Ball)
___ Nature/Environmental Ed.
(outdoor cooking, orienteering)
___ Special Activity
(crayfishing 4-square, relays, theme activities)
___ Tennis Class
___ Canoeing Class
___ Kayaking Class
___ Swimming Instruction (level:_____)
___ Horseback Riding Lessons
(preparing child to perform)
Free Time
(Number from 1-10)
___ Boat Slide
___ Cable Ride
___ Creek Activities
(rope swing/barge, burma bridge)
___ Crafts
___ Tournaments
___ Art
___ All Camp game
___ Racket Sports
___ Lifeguarding
___ Working the Store
3
SKILLS & ABILITIES CONT.:
Spiritual Emphasis
Other Areas of Talent
Please check if you have had
experience in doing or would be
willing to assist in.
____ Bible Study
____ Sharing your
testimony
____ Work with Youth
____ Instrument: __________
____ Sewing
____ Videography
____ Camping Skills
____ Singing
____ Photography
____ Typing/Computer
____ Square Dancing
____ Other: ______________
 (Ages 12-13)
 (Ages 14-16)
____
Song
Leading
____ Child Evangelism
Stories
____ Prayer Time
AGREEMENT:
Your Best Overall
Activities to Teach
1.
2.
3.
4.
5.
6.
7.
Other Skills
Any other activity in which you
have experience. Like: a care
giver, web design, juggling etc.
1.
2.
3.
4.
5.
I certify that the answers provided in this application are true and complete to the best of my knowledge. In the event of employment, I
understand that false or misleading information given on my application or during my interview(s) may result in termination of
employment.
I realize that my behavior is a reflection on both Antietam Recreation and the Lord Jesus Christ since this is a Christian facility. By my
involvement, I understand I will be considered an example and a leader.
I accept responsibility for the safety and well-being of the campers that are assigned to my supervision. I will strive to have a love for them
and care for each person on an equal level. I will strive to be a servant without complaining. I realize that a spirit of cooperation is vital to
my interaction with the other staff members.
“UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT,
PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE
DETECTOR OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND
SUBJECT TO A FINE NOT EXCEEDING $100.”
Applicant’s Signature: __________________________________________________________________ Date: _____/______/______
Don’t forget:
 Make sure the application is completely filled out.
 Make sure that a picture is attached to the front of the application.
4
2017 Rate: $______
2017 STAFF CONTRACT (office use only)
____________________________________ __________________________________
LAST NAME
Applying for:
 CIT (16-18)
 Counselor (18 and up)
FIRST NAME
___________________________________ ____________________________ _________ _________________
STREET ADDRESS
CITY
________________________________________
HOME PHONE
STATE
_____________________________________
WORK PHONE
ZIP CODE
__________________________________________________________
EMAIL
In the sections below, please mark your AVAILABILITY to work. If you are not sure about a day or week, it would be better NOT to mark
it, as this is considered a commitment on your part. Based on your availability and our needs, we will notify you of which dates you have
been selected to work. The more available you are, the more likely you are to receive your dates.
SCHOOL GROUPS: 9:30 am-1:30 pm
OPEN HOUSE:

 I am available for prep & cleanup
 the week of 5/1-5/5

 Saturday, 5/6, 12:15-6:15
 
 Fri. 5/12
 Mon. 5/15
 Tues. 5/16
 Wed. 5/17
 Thurs. 5/18
 Fri. 5/19

 Mon. 5/22
 Tues. 5/23
 Wed. 5/24
 Thurs. 5/25
 Fri. 5/26
 Tues. 5/30
 Wed. 5/31
 Thurs. 6/01
 Fri. 6/02
CAMP WEEKS: Normally 8:45 am-4:00 pm Monday-Thursday and 9:15 am-5:00 pm on Friday
MEETING FOR ALL DAY CAMP STAFF: Saturday, June 3rd from 6:00-7:30 pm (New staff 4:00-7:30 pm)
SKILL TRAININGS: May 13-June 3 (Includes such things as Lifeguarding, First Aid, CPR, canoeing certification etc. Most classes will be in
the evenings. Not all classes will be necessary for each staff member. Additional details to follow.)
 Please check to confirm that you understand you must attend this meeting and any other required training for your activity.




Week 1: June 5-9
Week 2: June 12-16
Week 3: June 19-23
Week 4: June 26-30




Week 5: July 3-7
Week 6: July 10-14
Week 7: July 17-21
Week 8: July 24-28




Week 9: July 31-Aug. 4
Week 10: August 7-11
Week 11: August 14-18
Week 12: August 21-25
 Week 13: August 28-Sept. 1
 Final Campfire: Sept. 1, 5:00-9:30 pm
SATURDAY GROUPS: Day Groups 12:00 pm- 4:00 pm; Evening Groups 5:00 pm- 9:00 pm

Day
6/03
 Evening
6/17

Evening
7/01
 Day 6/10
 Day 6/24
 Day
7/08


 Evening 6/10
 Evening 6/24

Evening
7/08

 Day 6/17
 Day 7/01

Day
7/15









Evening 7/15
Day 7/22
Evening 7/22
Day 7/29




Evening 7/29
Day 8/05
Evening 8/05
Day 8/12





Evening 8/12
Day 8/19
Evening 8/19
Day 8/26
Evening 8/26
PAY DAYS: Paychecks are available after 3:30 pm or mailed the following day.
Tues., May 23
May 8-20:
May 22-June 3: Tues., June 6
June 5-17:
Tues., June 20
June 19-July 1:
July 3-15:
July 17-29:
Tues., July 4
Tues., July 18
Tues., Aug. 1
July 31-August 12: Tues., Aug. 15
August 14-26:
Tues., Aug. 29
August 28- Sept. 9: Tues. Sept. 12
By signing, I agree that this form correctly reflects the times I am committing to work during 2017.
________________________________________________________________________ ______________________________________
SIGNATURE
DATE
RETURNING STAFF Please select the activities that you would be interesting in teaching/leading (check as many as apply).
Regular Activities:
 Adventure
 Field Sports
 Games
 Nature
 Special Act.
 Tennis
 Kayaking
 Canoeing
 Swim Teacher
 Horses
 Art/Crafts
 Baking
 Drama
 Library
 Dance
 Antietam Has Talent
 Sp Proj/Nerf
 Store
 Carousel
 Dress Up/Costuming
 Jr Camp
 Teen Camp
 Bottom of Boat slide
Special Assignments:
 MC – Do daily announcements, explain electives, lunch prayer, supervision and dismissal as well as hand out shirts.
On Fridays you will be doing the awards ceremony.
 Groups 1 & 2 - Assist with getting six and seven year old campers to their destination, being responsible for helping
them with their money and sunscreen.
 Medical - Tend to injuries and illnesses as they come in, write up detailed reports and put them in the medical log.
You will be making follow up calls to parents and assisting the front receptionist.
 Equipment Manager - Responsible for getting out all equipment for activities and assisting counselors when they
need something. You will need to keep things organized and put away items at the end of the day. If new equipment
is needed you will need to let Mary or Jessica know.
 Saturday Group Coordinator - Setting up and cleaning for groups. Managing staff and working with group leader.
You will need to make announcements and be available for any problems that may arise.
 I would be interested in moving to a variety of activities throughout the summer.
OR
 I would prefer to remain at one primary activity throughout the course of the summer (please list below):
_____________________________________________________________
STAFF MEDICAL INFO
_______________________________________________________________________________
NAME
__________________________________________________ ____________________________
PHYSICIAN’S NAME
________/ _________/________
DATE OF TETANUS SHOT
PHONE NUMBER
Over 18 years old
Under 18 years old
__________________________________________________ ____________________________
EMERGENCY CONTACT
PHONE NUMBER
__________________________________________________
RELATIONSHIP
_____________________________________________________________________________________________________________
PLEASE LIST ANY PHYSICAL ISSUES
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________