CAMP COUNSELOR APPLICATION FORM
Background: Quest Camps will focus on activities that encourage lifetime fitness good eating habits, and tobacco prevention, as well as tie in STEM (Science,
Technology, Engineering and Math) at the same time. The camps are targeting youth who will be entering grades K-8 this fall. Camp will run from Monday, June
1 through Friday, June 5. Camps will run from 9:00 am until 3:00 pm Monday-
Thursday and 8:00 am until 3:00 pm Friday. The camps will be held at various locations in Loudon.
Each camp counselor will be responsible for no more than
10 campers and will be assisted by another counselor. You must provide your own transportation to and from camp and will be expected to arrive no later than
8:30 (7:30 on Friday) each morning of camp.
Please complete ALL of section A as this information is required to complete a background check and to pay you your travel stipend.
Section A:
NAME: _____________________________________________________________________
ADDRESS: _____________________________________________________________________
_____________________________________________________________________
CITY/ST/ZIP: _____________________________________________________________________
TELEPHONE NUMBER: ______________________________________________________________
PERSONAL CELL NUMBER: ___________________________________________________________
EMAIL ADDRESS: ____________________________________________________________________
NAME OF COLLEGE OR SCHOOL (if currently enrolled): ______________________________
ARE YOU CURRENTLY EMPLOYED? IF SO, WHERE?_______________________________________
Do you have permission from your employer to work this camp? (If it will interfere with your regular work schedule) _____YES _____NO _____N/A
DRIVER’S LICENSE # OR STATE ISSUED IDENTIFICATION # ________________________________
STATE IN WHICH LICENSE IS ISSUED: ________
PLEASE LIST THE NAMES AND PHONE NUMBERS OF TWO PEOPLE WE CAN CONTACT FOR
REFERENCES:
1. NAME:______________________________ PHONE__________________________________
2. NAME:______________________________ PHONE__________________________________
SOCIAL SECURITY NUMBER (18 Years and older only):__________________________________

Section B:
PLEASE CHECK ANY OF THE FOLLOWING AREAS IN WHICH YOU HAVE SOME KNOWLEDGE OR
EXPERIENCE :
_____HIKING _____SWIMMING _____BIKING _____SHUFFLEBOARD _____BADMITTON
______GEO CACHING ______PING-PONG _____GARDENING _____SURVIVAL SKILLS
_____ OTHER SPORTS/EXCERISE/ACTIVITIES: PLEASE LIST:_____________________________
STEM (SCIENCE, TECHNOLOGY, ENGINEERING, MATH) TOPICS:
_____ PLANT/ANIMAL IDENTIFICATION _____ WATER CYCLE _____ BODY SYSTEMS
(PARTICULARLY CARDIOVASCULAR AND DIGESTIVE) _____ NUTRITION _____ OTHER
(PLEASE LIST: ______________________________________________________)
ARE YOU CURRENTLY CPR & FIRST AID CERTIFIED? _____YES _____NO
IF NOT, ARE YOU WILLING TO BECOME CERTIFIED PRIOR TO CAMP? _____YES _____NO
CAN YOU SWIM? (In order to be a senior counselor you must know how to swim; it is preferred all counselors know how to swim well) _____YES _____NO
NOTE :
If you are over the age of 18 (and have graduated high school by June of 2015) you will be assigned a
Senior Counselor position at Energy Quest camp or a Junior Counselor position at STEM Quest camp.
Your travel stipend will be in the form of a check for $250. Total number of positions: 8.
If you are under the age of 18 you will be assigned a Junior Counselor position at Energy Quest camp or
Adventure Quest camp. Your travel stipend will be in the form of a gift card for $100. Total number of positions: 8.
WHICH GRADE LEVEL are you most interested in working with (Please number preference 1-3, 1 being your top choice)
______K-2 (Adventure Quest) ______3-5 (Energy Quest) ______6-8 (STEM Quest – must be18)
T-SHIRT SIZE: Small Medium Large XL XXL

VOLUNTEER STATEMENT OF COMMITMENT
As a counselor working the Loudon County Health Improvement Council, I have read and understand the following information:
All counselors for the camp will receive a travel stipend.
Attend an orientation meeting – day and time to be determined.
Report to their camps by 8:30 in the morning.
Be dressed in appropriate attire.
Use appropriate language.
Be prepared to demonstrate, teach and participate in the day’s activities.
All counselors will be provided insurance (liability and accident).
I understand and agree that as a counselor for the Loudon County Health Improvement Council’s
Quest Camps I will be subject to a background check.
Printed Name: ______________________________________
Signature: ______________________________________ Date: _______________________________
Please return this application no later than April 1 st to:
Melisa Fuhrmeister
Email: fuhrmeisterm@loudoncounty.org
Fax: (865) 988-7775
Mail to: 4380 Harrison Road, Lenoir City, TN 37771
APPLICANTS WILL BE CONSIDERED ON A FIRST-COME, FIRST-SERVE BASIS.
RETURN APPLICATIONS EARLY.