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.