The National Conference for Community
and Justice of the Piedmont Triad, Inc.
713 North Greene Street
Greensboro, NC 27401
Counselor Application for NCCJ 2012 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 rank the session(s) you can attend in order of your preference; 1 st, 2nd. Remember you must
attend the full week.
____ Session I: June 24 - June 29
____ Session II: July 15 - July 20
____ I can attend either session.
(arrive June 23rd for on-site staff training)
(arrive July 14th 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
_____/_____/_____
Date of Birth
Primary email address _____________________________________________
T-shirt Size _________
Current School and Class Year:________________________________________________________________
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) ________________________________________________________
Certifications: (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
 Sports (specify)
 Writing
 Campfire Set-up
___________________________
 Languages Spoken
 Music / Performing Arts
___________________________
_________________________
(specify)
 Musical Instrument(specify)
 Other (specify)
___________________________
_________________________
_________________________
___________________________
 Organizational Ability
___________________________
 Hiking
 Photography
_______________________
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 ___________________________________
Phone number __________________________
Relationship ____________________________________________________________________________
Name ___________________________________
Phone number __________________________
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 what
you described impacted you.
COMMITMENT:
I understand that if chosen as staff for ANYTOWN 2012, 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 2012 delegates; without adequate training we are unable to provide that experience.

New Staff Orientation (For New Counselors Only): Tuesday, June 5 (6:00PM-9:00PM)
Session I Counselor Training Dates
Tuesday, June 12 (6:00PM-9:00PM)
Saturday, June 16 (9:30AM-4:00PM)
Tuesday, June 19, (5:30PM-9:00PM)
Leave for BRCC Sat., June 23
Session II Counselor Training Dates
Tuesday, June 19 (6:00PM-9:00PM)
Saturday, July 7 (9:30AM-4:00PM)
Tuesday, July 10, (5:30PM-9:00PM)
Leave for BRCC Sat., July 14
ALL TRAINING SESSIONS TAKE PLACE AT NCCJ’S OFFICE.
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 2012 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 contact:
Hoyt Phillips, Program Consultant
Phone: (336) 272-0359 ext. 14
Email: programs@nccjtriad.org
Applications are due in the NCCJ office no later than 5:00 pm on Friday, March 16, 2012.
Staff selection notification will be made by early April.