Give details of any leadership roles held-both paid and voluntary.

Describe your teaching experience and, qualifications gained in connection with your activity choices. (qualifications, teams joined. offices held, trophies won, etc.)

2nd choice

Camp can be strenuous and demanding. You will need to be in good health.

Have you ever suffered from any serious or debilitating illness?
Do you have any physical limitations?
Have you ever had a nervous breakdown or psychiatric treatment?
Are you undergoing any sort of medical treatment?
Do you have any diet restrictions?
Comments
Do you have any criminal convictions? Have you ever been accused of or involved in an incident involving the sexual or physical abuse of a child?
If "yes" to either of these questions, please explain.
What contribution do you think you can make to camp?
How do you think that children might benefit from the camping experience?
Any other information you would like us to know to help us make a decision?

Employment History
Employer
Your Position
Telephone
Date
Employer
Your Position
Telephone
Date
Employer
Your Position
Telephone
Date

Certifications	Expiration Date	Any Explanation of Comments:
Standard First Aid
Advanced First Aid
Water Safety Instruction
Life Guard
CPR
CHA (Horse Certification)
Canoe/Kayak Instructor Certification
Other:

What is your minimum salary requirements for the summer?
I declare that the above statements are true. I will notify Camp Tall Timbers should circumstances change between now and the start of camp in such a way as to alter my answers on this form.
Name	Date

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