NEW CAMP COUNSELOR APPLICATION

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Date Application Sent:

CAMP HOPE TEEN LEADERSHIP FORUM COUNSELOR APPLICATION

Date Application Rec’d: All forms completed:

Yes

Cabin assignment:

Please return all completed forms to: AIDS Foundation Houston – Volunteer Services 6260 Westpark Suite #100, Houston TX 77057 Camp Hope – July 19-25, 2014 (Application due Friday, May 2, 2014) Teen Leadership Forum – June 19-24, 2014 (Application due Friday, May 2, 2014) Name: Address: City/State/ZIP: Mailing address (if different): List the last 3 addresses where you resided:

Date of Birth: _______________ Telephone Home: ( Mobile: (

Age: _______________

)

Work: (

)

Sex: _______________ )

E-mail:

Race/Ethnicity (please circle one):

African-American

Hispanic/Latino

White

Driver's License Number:

State:

Expiration Date:

Make/Model Vehicle:

Year:

License Plate #:

Asian

Other

Social Security #:__________________________

Maiden/Other Name(s): ___________________________________

Marital Status: ____________________________

Spouse’s Name: _____________________________________

Emergency Contact: ___________________________________________ Phone: (

)

T-shirt Size (please circle one):

Relationship: S

M

L

How did you hear about Camp Hope?

Why do you want to volunteer with Camp Hope?

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XL

XXL

XXXL

No

CAMP HOPE TEEN LEADERSHIP FORUM COUNSELOR APPLICATION Do you prefer to work with a specific age group of children? If so, explain specific experience and /or, training with this group:

Previous Camp Experience: (Staff or Camper): Previous Volunteer Work: Child Care Experience: HIV/AIDS Experience: Have you ever been arrested, charged with, convicted of, or received deferred adjudication with respect to any crime (except minor traffic offenses and DUI/DWI) resulting in a fine of less than $200.00 or jail time? If so, explain:

In the last five (5) years, have you ever been convicted of Driving While Intoxicated or Driving While under the Influence? If so, please explain:

Has your driver's license ever been suspended or revoked? If so, explain:

In the last five (5) years, have you ever been convicted of Sexual Offense? If so, please explain:

In the last five (5) years, have you ever been charge or has a report been made against you regarding negligent or abuse of a child? If so, please explain:

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CAMP HOPE TEEN LEADERSHIP FORUM COUNSELOR APPLICATION Have you ever been terminated for cause, asked to resign from a job for misconduct, or suspended or expelled from school? If so, explain:

Occupation: _____________________________________________ Employer's Name: ________________________________________ Address: ________________________________________________ Phone Number: __________________________________________ Can we contact your employer? Yes_____

No_____

Supervisor Name: ________________________________________ Last two employers (please include employment dates):

List three (3) references, at least one (1) professional and at least one (1) personal: NAME

RELATIONSHIP

ADDRESS

Note: We will contact two of the three references. Education: High School attended /Graduation date: College or other attended / graduation date or last year completed: Field of Study: Degree/Certification: Special Skills/Training:

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PHONE NUMBER

CAMP HOPE TEEN LEADERSHIP FORUM COUNSELOR APPLICATION Skill

Yes

Ski