Name_________________________________________________________________________________DOB____________________
Social Security #:___________________________________Email____________________________Phone_______________________
Home address______________________________________________________City______________________State______________
Employer________________________________________________________________Phone__________________________
Formal education highest grade completed_________________________________________________
Do you drive? ____yes____no Driver's license #__________________________________________
Have you ever been convicted of any crime in ANY manner to children? ____yes____no
Do you consent to a routine criminal backgroud check? ____yes____no
Have you ever volunteered at a kids day camp before? ____yes____no
Have you ever worked with special needs kids? ____yes____no
How did you learn of our program?___________________________________________________________________________________
Do you need hours reported to an agency? ____yes____no
When are you available? Month(s)___________________Week(s)___________________________Hrs per day________________
Please list 3 non-related references
1.Name__________________________________________________Phone_______________________Relationship_______________
2. Name_________________________________________________Phone_______________________Relationship_________
3. Name_________________________________________________Phone_______________________Relationship_________
Please list any special skills, hobbies, interests you would be willing to share at camp.
________________________________________________________________________________
_________________________________________________________________________________
Identify any medical conditions we should know about, e.g. asthma, diabetes___________________________________________
______________________________________________________________________________________________________
Identify any emergency drugs you may need_____________________________________________________________________
I give my permission to include my name and/or picture inall camp promotional material, newspapers, TV,
brochures, videos, etc. ____yes____no
Signature________________________________________Signature of parent if under 18________________________________
