Mount Tom Day Camp - Staff Application

In accordance with the Children's Online Privacy Protection Act, a person must be 13 years of age or older to complete and submit this form.

Please Fill Out & Complete All fields. Use The Pointer to Move Between Fields.

Name:

Social Security #:

Permanent Address

Street & Number:

City:

State:

Zip:

College Address

Street & Number:

City:

State:

Zip:

Home Phone:

Cell Phone

College Phone :

E-Mail:

Date of Birth:

Marital Status :

SingleMarried

Camp Age Children?

Child's Name:

Age:

School:

Grade :

Child's Name:

Age:

School:

Grade :

Child's Name:

Age:

School:

Grade :

Position(s) Applying For

Group Leader: Lifeguard: Clerical/Support: Administrator:
Counselor:

Specialist:

Specialty:

(hold down Shift key to select multiple items)

If you have taught other activities, please list here:

Dates Available:

From To

Applicant's Mount Tom History:

Camper:

Yes No

If Yes, Years Attended :

(i.e. 2001-2005)

Staff:

Yes No

If Yes, Years Worked :

Applicant's Other Camp Experience

Name of Camp:

Year(s):

Location:

Camper or Staff?

Name of Camp:

Year(s):

Location:

Camper or Staff?:

Name of Camp:

Year(s):

Location:

Camper or Staff?:

Educational Background

Grad School

Name of School:

Degree:

Area of Concentration:

Date of Degree:

College/Univ.

Name of School:

Year:

Major:

Degree:

Date of Degree:

High School

Name of School:

Grade:

Work History (Please list most recent first)

Job 1

Dates:

Position:

Employer Name:

Address:

Telephone:

Reason for leaving:

Job 2

Dates:

Position:

Employer Name:

Address:

Telephone:

Reason for leaving:

Job 3

Dates:

Position:

Employer Name:

Address:

Telephone:

Reason for leaving:

Job 4

Dates:

Position:

Employer Name:

Address:

Telephone:

Reason for leaving:

References:

Please list people who know your character, strengths, work ethic, personality, etc. (other than family).

Reference 1:

Name of Reference:

Phone:

Address:

Relationship to applicant:

Reference 2:

Name of Reference:

Phone:

Address:

Relationship to applicant:

Reference 3:

Name of Reference:

Phone:

Address:

Relationship to applicant:

Please explain your interest in this position for the upcoming camp season and how you can make a positive impact on our program. Discuss your previous experiences that are relevant to this position. Please share with us how you heard about Mount Tom.

Current Certifications: Multiple items may be chosen.

WSI
Lifeguard
CPR
RTE
FirstAid
RN

Program Skills

Next to the following sports/activities, put a "1" where you can organize and teach ; "2" by those you can assist :

Games/Relays
Swimming
Fitness/Acrobatics
Volleyball
Soccer
Tutoring
Table Tennis
Teen Activities
Nature
Whiffle Ball
2-Wheeler Bike
Music
Camp Songs/Cheers
Lacrosse
Horseback Riding
Gymnastics

Tennis
Martial Arts
Basketball
Arts & Crafts
Field Hockey
Track & Field
Early Childhood Activities
Developing Special Events
Origami
Football
Softball
Dance
Archery
Drama
Rock Climbing
Outdoor Education

Additional Skills: Please describe other areas of your expertise that might result in new programs for our campers (ages 3-13).

Do you have a valid drivers license?

Yes No State License #:

Do you have a chauffeur's License?

YesNo

Do you have a commercial drivers license?

Yes No

Do you have your own vehicle?

Yes No Make/Model/Year

Would you drive?

YesNo

Harassment:

The camp's policy is to prohibit all forms of harassment by our employees. This includes sexual, racial, religious, and other forms of harassment. Have you ever been accused of harassment of any person including, but not limited to workplace harassment? (Note: a prior accusation or conviction is not an automatic bar to employment. The type of conviction or accusation and when it occurred will be evaluated by the camp before any decision is made.)

Yes No

If yes explain:

Criminal Record:

Have you ever been convicted of a crime, other than a minor traffic offense? If yes please describe. (Note: a prior conviction is not an automatic bar to employment. The type of conviction or accusation and when it occurred will be evaluated by the camp before any decision is made.)

Yes No

If yes explain:

I authorize investigation of all statements herein, including any checks of criminal records, and release the camp and all others from liability in connection with same. I understand that, if employed, I will be an at-will employee unless there is an agreement or law which alters that status. Furthermore, I understand that any agreement must be in writing and signed by the designated camp official. I also understand that untrue, misleading, or omitted information herein or in other documents completed by the applicant may result in dismissal, regardless of the time of discovery by the camp.

Yes (Required)

48 Mount Tom Road New Rochelle, NY 10805 Tel: (914) 636-8130 Fax: (914) 576-3270 info@mounttomdaycamp.com

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