Application for 4-H Camp Counselor
Camp Bob Marshall
Return to the ____________ County Extension Office on or before May15th
Please Print Legibly
Last Name ______________________ First Name _________________________
Street Address ______________________________________________________
City ___________________ Zip Code ___________ County____________
Phone ( ) ______________ Age as of June 1 _________________________
E-Mail Address ____________________________________
Why would you like to be a camp counselor?
_____________________________________________________________________________________
_____________________________________________________________________________________
Have you ever attended a 4-H Camp or other youth camp? _____ If yes, please
describe your experience. . .
_____________________________________________________________________________________
_____________________________________________________________________________________
Write a brief biographical sketch, including specialized training in camping, leadership
experiences, previous Camp Counselor experience, 4-H projects, and experience or
training in other fields which might have a bearing a position of Camp Counselor
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Please rank the following camping areas: 1= those activities you can organize and
teach, 2= those activities you can assist in teaching, 3= those activities that are your
hobby.
____ Lead group singing
____ Photography ____ Camp fire programs
____ Play a guitar
____ Crafts
____ First Aid / CPR
____ Evening recreation
____ Archery
____ Swimming
____ Meal times
____ Nature
____ Canoeing
____ Flag ceremonies
____ Sports & Games ____ Campfire ceremonies
RECOMMENDATIONS: Two recommendations are required. Use the attached form. List each
person’s name, relationship to you and phone number or address. Attach the completed forms
to this application. This recommendation should be someone other than your county extension
educator and /or family member. You may use your 4-H Club leader, teacher, employer, etc. for
this recommendation.
1. ______________________________ ____________________________
Name
Address
______________________________ ____________________________
Phone Number
Relationship
2. ______________________________ ____________________________
Name
Address
______________________________ ____________________________
Phone Number
Relationship
____ I plan to attend the Counselor Training Camp
____ I cannot attend because ___________________________________________
Although I am unable to attend camp counselor training, I would like to be considered as a
candidate for camp counselor because:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
*** The “Recommendation for Camp Counselor Position” form must be filled out by your county
extension educator or another adult who is not related to you and must be returned with your
application or sent in by the individual filling it out.
I prefer to be a camp counselor at the following camp(s).
Rank your order of preferences.
_____ Session 1 Dates: June 21-24, 2010
Counties: Lincoln, Tripp, Pennington, Gregory, Shannon
_____ Session 2 Dates: June 25-28, 2010
Counties: Bennett, Butte, Lawrence, Meade, Custer, Fall River
_____ Session 3 Dates: June 29-July 2 2010
Counties: Perkins, Union, Lyman, Harding, Jones, Mellette, Ziebach, Hughes
By signing below, I acknowledge that I have read and agree to abide by the responsibilities and guidelines
contained in the 4-H Camp Counselor Job Description and Code of Conduct if selected as a camp
counselor. I understand and agree that I will be asked to call my parents/guardians immediately to pick
me up if I conduct myself in an irresponsible manner, which includes being out of my cabin after hours
and /or the possession or use of tobacco, alcohol, illegal drugs, or fireworks.
Applicant Signature _____________________________________ Date _____________
As the applicant’ parent/guardian, I have reviewed the application & agree to the conditions.
Parent/Guardian Signature _______________________________ Date _____________
I have reviewed the application. This applicant is a 4-H member in good standing within our local 4-H
program. If this applicant is not a 4-H Member do you have knowledge about him/her that you would
recommend him/her to be a camp counselor?
Yes _____ No _____ Please explain/give a brief recommendation on the back of this sheet.
Extension Educator’s Signature _____________________________ Date __________