Counselor Application

Address

Phone Number

Area Code Phone Number
E-mail
Do you check your email daily?

Yes No
Grade Entering next year 2023/2024
School/College next year 2023/2024
List dates you're available this summer
Are you CPR certified?

Yes No
Have you ever had a school suspension or expulsion? If so please provide history and details.
Have you ever had a delinquency adjudication? If so please provide history and details.
Have you ever been convicted of an assault or other offense? If so please provide history and details.
Returning counselors need not fill out the following info and can skip to the signature.
Share any skills, talents, and certifications you have that could be utilized in our camp.
Describe all previous experience that you have had with children ages 5-13. Specify the role that you played, the ages of the children, and how often you helped care for them.
Reference #1
Name (Reference #1)

First Name Last Name
Phone Number

Area Code Phone Number
Relationship to applicant
Reference #2
Name (Reference #2)

First Name Last Name
Phone Number

Area Code Phone Number
Relationship to applicant
Please be aware that you will need to be fingerprinted before you can work as a counselor, which is a Federal and State requirement for a criminal background check.
Signature
Date of Signature

Month Day Year
Should be Empty:

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Camp Gan Izzy Counselor Application Form