EmailMe Form - Waitlist Counselor Application: 2017 ESX

Applicant Info:

Name: *

First Last

Age:

Date of Birth (6 digits only, i.e. 040707) *

Grade Going Into: *

List your availability Monday, June 19th – Friday, July 28th.
Camp is closed Monday and Tuesday, July 3rd & 4th. If you are unsure of your availability, list when you will know. List each week separately.
Week of June 19th:
Week of June 26th:
Week of July 3rd:
Week of July 10th:
Week of July 17th:
Week of July 24th: *

This year’s camp will offer special areas for arts and crafts, sports, and more! Please list your own interests, hobbies and relevant experience. Ideas for projects in these areas are also appreciated. *

Your Address: *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Are you currently CPR-certified?

Yes

No

Your Email Address:

Your Phone Number: *

### - ### - ####

Did you attend ESX? (don't worry, applicants who attended aren't given preference)! *

Yes

No

Is this your first year applying to be a counselor at ESX? *

Education: List high school and graduation year *

Education: List any special training or skills *

Work Experience:

Employer *

Address *

Job Title *

Type of Business *

Name of Supervisor *

Supervisor's Email *

Supervisor's Phone *

### - ### - ####

Dates of Employment *

May we obtain references from the employers named above? Please write yes or no. If no, please name employer and list reason. *

Volunteer Work:

Please list relevant experience and duties involved.

Volunteer Work: *

Other Skills and Personal Attributes: *

References:

Employment, supervisor of volunteer work other person familiar with your skills as they apply to this position.

Name *

First Last

Phone: *

### - ### - ####

Relationship: *

Name *

First Last

Phone: *

### - ### - ####

Relationship: *

Emergency Contact Information:

Please enter the name and contact information for who should be contacted in the case of an emergency.

Name *

First Last

Relationship *

Day Phone *

### - ### - ####

Cell Phone: *

### - ### - ####

Email *

I certify that all the information given on this application is true and complete to the best of my knowledge and agree that any false or missing information may disqualify me for this position. By entering my initials and date below, I agree to the above statement. *