EMPLOYMENT FORM
Position Applying for:
Last Name:
First Name:
Sex:
Address:
City:
State:
Zip:
Phone:
Email:
Social Security #:
Birthdate (MM/DD/YY):
Age by 2008:
U.S. Citizen? Yes No
Children (Sex & Ages):

Educational Background
School now attending:
Grade or year in:
If in college, major:
Degrees achieved (check all that apply): High School BA/BS MA/MS PHD
Employment Background (list most recent employer first)
Name of Employer #1:
Phone:
Address:
Dates of Employment From: To:
Job Title:
Supervisor:
Reason for Leaving:
   
Name of Employer #2:
Phone:
Address:
Dates of Employment From: To:
Job Title:
Supervisor:
Reason for Leaving:
Camping Background
Name of Employer:
Phone:
Address:
Dates of Employment From: To:
Job Title:
Supervisor:
Reason for Leaving:
Special Abilities:
Please list areas of special abilities that you are qualified to instruct.
Personal References: List references other than relatives and friends.
Name:
Address:
City/State/Zip:
Phone:
Relationship:
   
Name:
Address:
City/State/Zip:
Phone:
Relationship:
   
Name:
Address:
City/State/Zip:
Phone:
Relationship:
Referred to Mill Road by:
Relationship:
   
If applying for a counselor or junior counselor position, what age group would you prefer?
Do you have valid Red Cross Lifeguard Certification? Yes No
Do you have valid Red Cross WSI Certification? Yes No
Are you certified in CPR? Yes No
Are you certified in First Aid? Yes No
List any special condition concerning your possible employment.
What are your salary requirements for the full camp season?
Have you ever worked at Mill Road? Yes No
If yes, when?
What Capacity?
Have you ever attended Mill Road? Yes No
If yes, when?
Do your brothers/sisters/children now attend Mill Road? Yes No
If yes, names:
Additional notes and comments you wish to make:
Please check each of the following
Are you, currently, under contract to any other camp? Yes No
If yes, which camp?
Have you ever been charged with or convicted of a crime involving physical, sexual or mental abuse of a child or an adult? Yes No
If yes, explain:
Do you give permission for your employment record and personal references to be checked by an outside reporting agency? Yes No

By completing and submitting this Employment Application you affirm that all information contained in this application is true and that you further authorize investigation of the information you have provided by outside agencies. If any statements made in this application are found to be either untrue or misleading, then this application becomes void and it will be sufficient cause for immediate dismissal in the event you have already been employed by Mill Road Day Camp. You also understand that Mill Road Day Camp may terminate your employment at any time and for any reason.