The National Conference for Community
and Justice of the Piedmont Triad, Inc.
713 North Greene Street
Greensboro, NC 27401
Counselor Application for NCCJ 2015 ANYTOWN Program
NCCJ ANYTOWN Counselors must have previously attended the ANYTOWN Program as an ANYTOWN
Delegate. Throughout the week at Blowing Rock Conference Center (BRCC), Counselors are expected to be
actively engaged by working well with other staff members, teaching songs, planning skits, contributing
positively to delegate morale, leading small discussion groups and supporting daily programs.
Please check the statements which apply to you. Remember you must attend the full week.
____ Session I: June 21 - June 26
____ Session II: July 19 - July 24
____ I can attend either session.
(arrive June 20th for on-site staff training)
(arrive July 18th for on-site staff training)
Please type or print legibly.
Name _______________________________________________________________________________________
_____________________________________________________________________________________________
Address (where you want your mail to go)
City
State
Zip
______________________________
Home Phone
_______________________________
Mobile Phone
Primary email address _____________________________________________
________/________/________
Date of Birth
T-shirt Size ________________
Current School and Class Year (if applicable):______________________________________________________
To ensure diversity at ANYTOWN, we ask that you please check any / all of the following that apply to you:
(This information is confidential and will be viewed by NCCJ staff only. It will not be used or disclosed for any other
purposes.)
Sex: F ____ M ____
1) Racial / Ethnic Identity & Heritage:
 American Indian or Native American
 Asian or Pacific Islander
 Bi-Racial / Multi-Racial (please specify)
 Black / African American
 Latino (a) / Hispanic / Chicano (a)
 Middle Eastern or Arab
 White / Caucasian / European American
 Other (please specify)
____________________
2) Religious Affiliation





Agnostic
Atheism
Baha'i
Buddhism
Christian
Denomination:






Hinduism
Islam
Judaism
Native American
Nonreligious Secular
Sikhism
 Spiritualism
 Taoism
 Other
______________
_______________________
Name of Church/House of Worship (if any) ________________________________________________________
Please check any certifications that you may have (please specify and include expiration date):
First Aid / CPR ________________________Other ___________________________________________________
Please list any skills that you can share at ANYTOWN (feel free to attach additional information)
 Art
 Campfire Set-up
 Music / Performing Arts
(specify)
___________________________
___________________________
 Hiking
 Sports (specify)
___________________________
___________________________
 Musical Instrument(specify)
_________________________
 Organizational Ability
 Photography
 Writing
 Languages Spoken
___________________________
 Other (specify)
___________________________
___________________________
___________________________
New Counselor Applicants Only: Please give the name, address and phone number of at least one individual
(not a relative) who has known you for one year or more.
Name #1 ___________________________________
Phone number __________________________________
Address ________________________________________________________________________________________
Relationship ____________________________________________________________________________________
Name #2 ___________________________________
Phone number ___________________________________
Address ________________________________________________________________________________________
Relationship _____________________________________________________________ _______________________
Essay Question
On a separate sheet of paper, please thoughtfully answer the following question that pertains to you. Typed
responses are highly preferred.
New Applicants: Based on your experience, please write an essay that responds to the following prompt:
“Before ANYTOWN I . . . . . . .After ANYTOWN I . . . . .”
In your essay, you may also discuss your involvement in the community since ANYTOWN.
Experienced Counselors: Please write an essay that discusses a memorable moment/event from the most recent
time that you were on staff as an ANYTOWN Counselor. Describe this moment or event and explain how it
impacted you.
Commitment:
I understand that if chosen as staff for ANYTOWN 2015, I must attend staff training as well as ALL days of
ANYTOWN. All training dates are mandatory. If you cannot commit to the training dates, please do not submit
your application. Training sessions are to ensure that ANYTOWN will be the best ANYTOWN for the 2015
delegates; without adequate training we are unable to provide that experience.
Training Dates:
New Staff Orientation: (for Session I & II new counselors only):
Session I Staff Training Dates:
Counselors Only-Monday, June 9th, 6-9 pm
All Staff-Tuesday, June 16th, 6-9pm
Leave for BRCC Saturday, June 20 th
Session II Staff Training Dates:
Counselors Only-Wednesday, July 9th, 6-9 pm
All Staff-Monday, July 14th, 6-9pm
Leave for BRCC Saturday, July 18th
Tuesday, June 2nd, 6-9 pm
At NCCJ
At NCCJ
At NCCJ
At NCCJ
At NCCJ
Disclosure:
By signing below, you consent to a criminal background check(s) and to provide any paperwork required
to complete the I-9 Form as required for all NCCJ residential program staff and volunteers.
Applicant Signature:___________________________________________Date:_______________________
Social Security Number: ___________________________________________________________________
Parent/Guardian Signature:
By signing below, I give my permission for the young person named above to apply as a Counselor for the
NCCJ of the Piedmont Triad ANYTOWN 2015 residential program.
Parent/Guardian: _________________________________________ Date: __________________________
(if applicant is under 18)
Selected applicants will be contacted to schedule an interview with a member of the NCCJ Program Staff.
If geographic location prevents an applicant from coming to our office, the Program Department will
schedule a phone interview.
MAIL, FAX OR DROP OFF YOUR APPLICATION TO:
NCCJ ANYTOWN Counselor Application
NCCJ of the Piedmont Triad, Inc.
713 North Greene Street
Greensboro, NC 27401
Fax: (336) 272-1814
If you have questions, please call (336) 272-0359.
Applications are due in the NCCJ office no later than 5:00 pm on Monday, March 21, 2015.
Staff selection notification will be made by mid-April.