29 Pleasant Grove Road Port Murray, NJ 07865 Phone: (908) 832­7264 Fax: (908) 832­6593 www.crossroadsretreat.com An Ecumenical Ministry of the Episcopal Diocese of Newark and The Evangelical Lutheran Church in America, New Jersey Synod Summer Staff Application Name:​
________________________________​
​
Email:​
________________________________ I am applying for:
☐ Staff ☐ Jr. Counselor (if completed L.I.T program) Will you be over 18 by June 24, 2016? ☐Yes ☐No Will you be over 21? ☐Yes☐ No The summer starts June 24 and ends September 3 (some positions may start and end earlier). Please explain any scheduling conflicts you might have during the camp season. Staff are expected to be at camp all summer unless dates are pre­approved: Please check the box above your preferred mailing address ☐ Permanent Address: ☐ School Address (if applicable): City, State, Zip City, State, Zip Home Phone: Cell Phone: EDUCATION Highest Level of School Attended/Attending:
City/State: Major Course of Study:
Graduation Date: EMPLOYMENT/VOLUNTEER EXPERIENCE 1. Employer/Supervisor:
City/State:
Position:
Dates Worked:
Phone: Reason for Leaving: Position:
Dates Worked:
Phone: Reason for Leaving: Position:
Dates Worked:
Phone: Reason for Leaving: 2. Employer/Supervisor:
City/State:
3. Employer/Supervisor:
City/State:
(Please add any other applicable work experience on a separate page.) CAMP & CHURCH INFO Most Recent ​
Church​
:
City/State:
Significant Roles or Positions:
Dates Worked/Attended: Position ​
(camper or staff, and responsibilities):​
Dates Worked/Attended: Most Recent ​
Camp​
:
City/State: POSITIONS AVAILABLE Place a # (1­3) next to the positions you would consider in order or preference. Counselor ___
Kitchen Staff ___
Maintenance staff___ Leadership ___
Summer Program Coordinator ___
Day Camp Director ___ Day Camp Counselor ___
Little Adventure Leader ___
Summer Chaplin ___ SKILL INTEREST OVERVIEW Please mark a "T" next to the activities you can Teach and/or have a high level of skill. Mark a "D" next to the activities you like to Do and have Done. Singing Arts & Crafts Dance Basketball Story telling Guitar Games Skit Making Volleyball Rock Climbing Drama Foreign Language (list)​
: Photography Soccer Ropes Course Song Leading Hiking Environmental Education Swimming Lifeguard Worship Leading Bible Study Fire Building Canoeing Group Building Please complete the following with your first thoughts. Use only the space provided. I enjoy… Jesus said… I love… God is… Camp is… Is there anything else you would like us to know about you? ADDITIONAL INFORMATION List any applicable certifications you have, and their expiration date (life­guarding, WSI, CPR, First Aid, challenge course, etc): Are you interested in taking the lifeguard course at camp prior to staff training?( ​
tentative dates June 13­16)​
​
☐​
Yes ☐
​​
No Are you interested in taking the high and low ropes course training prior to staff training? (t​
entative dates are for late May​
) ☐​
Yes ☐
​​
No Have you been convicted of child abuse or sexual offense? ____ If yes, explain__________________________________ Have you been convicted of a felony? ____ If yes, explain __________________________________________________ Please list the number and state of your Driver’s License: ___________________________________________________ State law requires that your service at camp be contingent upon passing an FBI background/fingerprint test. I certify that the answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. The applicant understands that neither this document nor any offer of employment from the employer constitutes an employment contract unless a specific document to that effect is executed by the employer and employee in writing. Signature of Applicant ___________________________________________________ Date ____________ We consider applicants for all positions without regard to race, color, sex, national origin, or the presence of a non­job­related disability. Cross Roads Outdoor Ministries does withhold the right to base employment decisions on religious beliefs.