NEW CAMP COUNSELOR APPLICATION

DAMAGE OR PERSONAL INJURY, INCLUDING DEATH, THAT MAY BE SUSTAINED BY ... attorney's fees, court costs, and other expenses resulting from the .... Medical Sciences, LSU Health Baton Rouge, LSU/Tulane in New Orleans and ...
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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