INSTRUCTIONS: Print this form, complete it, and mail it to the address at the end of the application.

NAME:_______________________________________________________ DATE:______________

HOME ADDRESS:____________________________________________________

CITY:__________________________ STATE:________ ZIP:__________________

HOME PHONE:__________________________ SCHOOL PHONE:__________________________

SCHOOL ADDRESS:__________________________________________________

CITY:__________________________ STATE:________ ZIP:__________________

PRESENT CLASS IN SCHOOL (Circle one): high school senior, college freshman, sophomore, junior, senior, graduate

AGE:_______ BIRTH DATE:____________ HEIGHT:_________ WEIGHT:_________ RELIGION:_________________

SINGLE:___ MARRIED:___ DO YOU REQUIRE A SPECIAL DIET?_____ DO YOU SMOKE?_____

HAVE YOU EVER BEEN CHARGED WITH CHILD ABUSE?______

HAVE YOU EVER BEEN CHARGED WITH A MISDEMEANOR? ______ A FELONY?_____

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POSITION DESIRED ______________________________________ SOCIAL SECURITY NUMBER_______________

SKILLS: Single check the items below in which you gave some skill and double check those in which you could instruct others.

ARCHERY____ ARTS AND CRAFTS____ DANCE____ GROUP SINGING____ HIKING____ INDIAN LORE____

HORSEBACK RIDING____ SWIMMING____ TENNIS____ GYMNASTICS____ VOLLEYBALL____ SOFTBALL____

DO YOU HAVE A RED CROSS LIFESAVING CERTIFICATE?_____ WATER SAFETY INSTRUCTOR’S?_____

WITH WHAT AGE GROUP DO YOU WISH TO WORK?______________________

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EXPERIENCES, INTERESTS, AND ACTIVITIES: List the experiences, training, and courses you have had and the clubs or activities you have participated in which would equip you for the position. **

MOTIVATION: State briefly why you want to be a counselor at Camp Strawderman. **

REFERENCES: Give the names, addresses, and phone numbers of three references.

**If you need additional space, use the back of this form.

Mail To: Mrs. Margaret Gouldman, 10902 Brookwood Ave. Upper Marlboro, MD 20772