Our Lady Queen of Peace Ranch (Southern Alberta)
E-mail: info@ourladyqueenofpeaceranch.com
Box 390 Bragg Creek, ABT0L 0K0
Ph: (403) 949-2044
Ltd
Fax: (403) 949-2042
LIT Application 2015
Applicant Information:
Last Name: __________________________________
Birth date: ____________________________________
First Name: __________________________________
Age as of June 1: _______________________________
Gender: M/F
School Attended: ______________________________
Phone Number: _______________________________
Grade completed as of June 31: ___________________
e-mail: _______________________________________
Guardian Contact Information:
Name: _______________________________________
e-mail: _______________________________________
Address: _____________________________________
Secondary contact: _____________________________
Relationship to applicant: _______________________
Relationship to applicant: ________________________
Home Phone: _________________________________
Phone number: ________________________________
Cell Phone: ___________________________________
Alternate phone number: ________________________
Emergency Information:
AHC #: _______________________________________
Emergency contact name:________________________
Doctor’s Name: ________________________________
Phone Number (primary): ________________________
Doctor’s phone number: _________________________
Phone Number (alternate): _______________________
Previous Camp Experience:
Have you attended OLQP as a camper? _____________
If so which ones and for how long?
If so how many years? __________________________
_____________________________________________
Have you attended other summer camps before?
_____________________________________________
_____________________________________________
_____________________________________________
Why did you choose to apply as an LIT at OLQP?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Please list any experience you have working or volunteering with children:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
What skills do you think are important to have as a counsellor?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
What areas do you think you might struggle with as an LIT and aspiring counsellor?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
What do you think you can bring to the program?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
What do you hope to gain as an LIT at OLQP this summer?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Is it your goal to one day work as a counsellor at OLQP? Why?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
If you could bring anything new and exciting to the Ranch be it a program, guideline, knowledge or attitude based
what would you bring and why?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
PLEASE READ CAREFULLY BEFORE SIGNING
I hereby certify that the information provided on this application is accurate to the best of my knowledge and subject to verification by the Our
Lady Queen of Peace Ranch (Southern Alberta) Ltd. I authorize the schools, persons, previous employers, agencies and other organizations named
in this application to provide the Our Lady Queen of Peace Ranch (Southern Alberta) Ltd. (its authorized employees, agents, and/or
representatives) with any relevant information that may be required to reach an employment decision and hereby release any such schools,
persons, previous employers, agencies and other organizations from any and all liability which they might other-wise incur as a result. I understand
that any misrepresentation or omission of a material fact on my application may be justification for refusal of employment.
In the event of my employment, I will comply with all Policies and Procedures as set forth by the Our Lady Queen of Peace Ranch (Southern
Alberta) Ltd. in training and/or policy publications and any other communications distributed to employees. I understand a condition of my
continued employment will be my compliance with the Our Lady Queen of Peace Ranch (Southern Alberta) Ltd. Policies and Procedures.
I understand that the completion of this form does not guarantee me my status as an applicant or any consideration of employment unless I meet
the minimum qualifications required of the position of which I am asking to be considered. I also understand that my involvement in this program
does not guarantee employment upon its completion and understand that this is an unpaid position. I also understand that the Director of
Programming reserves the right to remove me from the program at anytime.
I have read the above statements and accept the same as a condition of my employment with the Our Lady Queen of Peace Ranch (Southern
Alberta) Ltd.
Applicant Signature: __________________________________
Date: _______________________________
Parental Acknowledge and Release:
By signing this form, I acknowledge and agree as follows:
· I have carefully read the parent information available at
http://www.ourladyqueenofpeaceranch.com/nuke/OtherPages/ParentInformation/tabid/128/Default.aspx I understand the activities which are
offered at the Ranch and the risks involved in those activities. I understand that my child will be taking part in those activities unless I have
clearly indicated on this document that my child should not take part in an activity.
· I understand the facilities and staff assistance which are available at the Ranch and the limitations on what those facilities and staff can provide.
As parent or guardian of the applicant, I fully accept all risks which might be entailed by a camping experience at Our Lady Queen of Peace Ranch
(Southern Alberta) Ltd.
· I certify that the contents of these forms completed for my child are true and complete.
· I understand that for the purpose of protecting the safety and well-being of campers, the information on this form will be provided to counsellors
and other Ranch staff on a need-to-know basis. This information will otherwise be kept in confidence, in accordance with the OLQP Privacy
Policy, a copy of which is available upon request, or unless disclosure is otherwise required by law.
· This health history is correct to the best of my knowledge, and the person herein described has permission to engage in all prescribed Ranch
activities, except as noted by me. In the event I cannot be reached in a medical or mental health emergency, I hereby give permission to the
physician selected by the Director, Programming to hospitalize, secure proper treatment for, and to order injection, anaesthesia or surgery for
my child as named. I agree to pay any and all charges not covered by my medical plan (i.e. medication; ambulance; etc.)
· On my own behalf, and on behalf of my child, I release Our Lady Queen of Peace Ranch (Southern Alberta) Ltd., its officers, directors, employees
and related entities, from all liabilities, claims and causes of action of any nature arising from or related to any injury suffered by my child while
attending the Ranch or participating in any related activities, including damage, loss, theft or destruction of property, injury or death, other than
those resulting from gross negligence.
Signature of parent/guardian:
Date
Name of parent/guardian (please print)
Phone