Application Form

Please print or type

SECTION 1 – Personal Information

Name _________________________________________________________________

Address ___________________________________________________________________

Street City Province Postal Code

Telephone Number ______________________ E-mail _____________________________

Permanent Address (if different from above)

____________________________________________________________________________

Street City Province Postal Code Phone #

Birth Date ______________ Age: _______ Sex: M / F

Day/Month/Year

Social Insurance Number _______________________________________________

Language Spoken: English ___ _____Some _____Well _____Fluently

French ___ _____Some _____Well _____Fluently

Other ________

Church Affiliation:

Denomination to which you belong ______________________

Church _______________

Education:

High School __________________________________________________ / ______________

School Level/Grade

CEGEP/College _________________________ / ___________________ / _______________

School Program Level/Grade

University _________________________ / ______________________ / _______________

School Program Level/Grade

Work Experience:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SECTION 1 (cont’d) – Personal Information

Camp Experience:

Have you ever attended camp as a camper? ______ For how long? _________

Which camp(s)? ___________________________________________________

Have you ever been a counsellor at a children’s camp? _________ For how long? ____________

Which camp(s)? _______________________________________

Do you smoke? Yes / No

SECTION 2: Skills and Qualifications

Have you ever been part of a group that studied the Bible? ___

If so, please give the name of that group and describe:

Have you ever led a Bible study group or confirmation class? If so, please describe:

Please circle any of the following activities in which you would say you have some proficiency; place an L beside those activities you would be willing to lead. (Please add any activities that are not mentioned in which you have some proficiency on the line provided.)

Arts & Crafts Construction skills Dance

Drama/Mime Face Painting Football

Knot Tying Leading Campfire Nature Study

Outdoor Cooking Puppet Making Singing

Soccer Soccer Baseball Softball Swimming Volleyball Writing

___________ ______________ _____________

SECTION 2 (cont’d): Skills and Qualifications

Please list any courses you have taken or teams you have been on, in the activities you are willing to lead.

Our camp program uses station through which the children cycle through during the day. Each of the stations requires 1 or (usually) 2 leaders. Please number the following activities in the order in which you would prefer to lead or help lead them (1 as the highest or first choice)

___ Craft ___ Recreation and Snack ___ Music

___ Bible story teller/dramatist ___ Mission Storyteller ___ Preschool

Other Qualifications: Please list (including certificates held and courses passed)

Swimming &/or Life Saving ______________________________________________________

First Aid ______________________________________________________________________

Counsellor Training _____________________________________________________________

Please describe any work you have done with children that has not already been described.

Please list any musical instruments that you play: ______________________________________

SECTION 3: References and Terms of Agreement

Please supply the names and address of two people who know you well. One must be your current pincicple/guidance counsellor/teacher or employer or recent employer (ie within the last year). Immediate members of your family i.e. parents, siblings, spouse, aunts, uncles, cousins, grandparents, may not be used.

Note: New Staff must give these people a Reference Form to complete and mail to Fort Haldimand Camp.

Name________________ Tel _________________ Position _________________________

Address ____________________________________________________________________

Street City Province Postal Code

Name________________ Tel _________________ Position _________________________

Address ____________________________________________________________________

Street City Province Postal Code

Please note: All applicants are required to produce a Police Record Check.

To the best of my knowledge, the information I have provided on the form is accurate and I give permission to Fort Haldimand Camp to verify this information.

__________________________________________ ____________________

Signature of Applicant Date

I have read the Quebec Diocesan policy on sexual harassment and abuse and Fort Haldimand Camp’s policy on Drugs, Alcohol and Sexual Relations, and agree to honour them if selected to serve as a counsellor.

_______________________________________________________ ____________________

Signature of Applicant Date

I consent to my child serving on staff through the Diocese of Quebec’s Camp Program and have read the Staff Policies.

_______________________________________________________ ____________________

Signature of Applicant’s Parent (if applicant is under 18) Date

Hosted by www.Geocities.ws