Kings Bay Y at Windsor Terrace
Summer Day Camp Employment Application 2017
Date: __/__/__
Date: __/__/__
Position Applying For: ______________
Age
Group
Preference:
1. __________ 2. __________
Position
Applying
For: ________________
Age Groups: (4-6), (7-11), (12-14)
Basketball
Age GroupCamp______________
Preference: 1. _______ 2. _______
Soccer Camp__________________
Name: _______________________
Age: ____
RECENT PHOTO
Home Address: ___________________ Apt: ____
City: _____________ State: ____ Zip Code: _________
Home Phone: (___) ___-_____ Cell Phone: (__) ___-_____
*Please make sure this is accurate*
Email Address: ___________________________@_________
*Please make sure this is accurate*
Emergency Contact Name: _______________________ Number: (___) ___-_____
Additional Positions [must choose one, i.e. Bus, early or late]
Please circle the additional positions below that you are interested in.
Bus Counselor [Neighborhood: ________________]
or
Please pick and check off one of the following:
1) Early Drop Off Counselor (Must come in at 7:30AM each morning) ____
2) Late Pick Up Counselor (Must be able to stay until 6:00 PM every day and responsible
for staying with children if parents are running late)____
Note: It is not possible to combine being a bus counselor, with either of the extended day positions. However, it is possible to be both
early drop off and late pick up.
Education
School
College
High School
Other
School Name/Number
Major
# Years Completed
Kings Bay Y at Windsor Terrace
Summer Day Camp Employment Application 2017
Our Staff Shabbaton & Training is from June 16, 2017-June 18, 2017; you are not eligible
to receive employment unless you attend. Can you attend? __Yes __No
References
Please list 3 adults who can be contacted regarding your abilities and experience.
**This information is only required of new applicants. Returning staff, leave this blank.
Full Name
Telephone Contact #
How do they know you?
1.
2.
3.
Certifications (please check all that apply) [you must provide certification 2 weeks prior to camp]
__ Adult CPR
__Child CPR
__First Aid
__Life Guard Training
Background Check (please answer as fully and exactly as you can)
Social Security #: _____________
(we will not give this to anyone, only use it for a background check)
Have you been charged with any crimes? ___Yes ___No
If yes, please explain in detail: _________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
I, _____________ certify that the above information is accurate and complete to the best of my knowledge and
that employment may be impacted if information is omitted or inaccurate. Furthermore, I understand that it is my
responsibility to inform the Kings Bay Y Summer Day Camp of any changes to my information as stated.
Signature: _____________________________ Date: ____________
For Office Use:
Interview Date:_______________
Interview Time: ______________
Rating (1-10):_______________