Camp Kesem Counselor Application
Camp Kesem Dates: August 13th-18th 2011
Mandatory Training Dates are March 26, 2011 and August 12, 2011
Desired position:
If you wish to be considered for more than one position, please rank your preferences in order, with one (1) being most desired and
three (3) being least desired.
___ Cabin Counselor
___ Program Counselor -- Please circle area(s) of interest: arts & crafts, drama, sports,
adventure/team building
___ Unit Leader – Leads the counselors in each cabin
I am applying for:
___Regular Program only
___Teen Program only
___Both Regular and Teen Programs, but if accepted, I would prefer: ________________
Note: Teen Program counselors must have completed two years of college by the start of camp. In addition, they must have at least one
year of Camp Kesem experience as a counselor or have separate experience working with teens.
First Name:
Last Name:
Date of birth:
Age:
Sex:
M
F
Major/Department:
Year in school (please circle): Freshman
Sophomore
Junior
Senior Grad
School Address:
Phone – Dorm:
Email:
Cell:
Dorm and Dorm Room (if applicable):
Please list any Red Cross certification or equivalent:
___ First Aid (expires
/
___ CPR (expires
/
/
/
___ Lifeguard Training (expires
)
)
/
/
___ Other _________________ (expires
)
/
/
)
If you speak another language, please list below with your level of fluency:
Please provide two references below. References should not be given by relatives and at least one should
come from a past employer.
1. Reference Name:___________________________ Relationship to You:______________________
Phone:_(_____)_________________ (work___home___)
E-mail:______________________
2. Reference Name:___________________________ Relationship to You:______________________
Phone:_(_____)_________________ (work___home___)
E-mail:_______________________
Rev. 9/10
© 2004 Camp Kesem National. All Rights Reserved. Camp Kesem & the Camp Kesem logo are trademarks of Camp Kesem National.
Camp Kesem Counselor Application
(You may type or clearly print your answers. Please limit each answer to 200 words.)
1. What, if any, experience have you had in working with youth, summer camps, etc.?
2. Please comment on your desire to work with children coping with cancer in the family.
3. What specific skills or qualifications do you have that would enhance the campers’
experiences at Camp Kesem?
4. Please comment on any experience you have with working as part of a team.
5. Name one of your strengths and one of your challenges in working with children.
6. Have you ever been arrested, charged or convicted of a crime? If yes, please explain.
7. Is there anything else you would like for us to know about you?
Rev. 9/10
© 2004 Camp Kesem National. All Rights Reserved. Camp Kesem & the Camp Kesem logo are trademarks of Camp Kesem National.
Camp Kesem Counselor Application
The following two questions are for Teen Program applicants only.
8. What experience do you have working with teens?
9. Why are you interested in the Teen Program?
Rev. 9/10
© 2004 Camp Kesem National. All Rights Reserved. Camp Kesem & the Camp Kesem logo are trademarks of Camp Kesem National.
Camp Kesem Counselor Application
BACKGROUND CHECK AUTHORIZATION
During the application process and at any time during the tenure of my volunteer service with
Camp Kesem National, I hereby authorize ChoicePoint Services Inc., on behalf of Camp Kesem
National, to procure a consumer report (known as an investigative consumer report in
California) which I understand may include information regarding my credit worthiness, credit
standing, credit capacity, character, general reputation, personal characteristics, or mode of
living.
This report may be compiled with information from credit bureaus, courts record repositories,
departments of motor vehicles, past or present employers and educational institutions,
governmental occupational licensing or registration entities, business or personal references,
and any other source required to verify information that I have voluntarily supplied.
I understand that I may request a complete and accurate disclosure of the nature and scope of
the background verification to the extent such investigation includes information bearing on my
character, general reputation, personal characteristics or mode of living.
____________________________________
Volunteer Name
__________________
Date
___________________________
Volunteer Signature
________-_____-__________
Social Security Number
______/______/______
Date of Birth
____________________________________________________________________
(Permanent/Parents’ Address)
______________________________________________ __________ _________
City
State
Zip
Note: ALL fields above are required.
Rev. 9/10
© 2004 Camp Kesem National. All Rights Reserved. Camp Kesem & the Camp Kesem logo are trademarks of Camp Kesem National.
Camp Kesem Counselor Application
BACKGROUND VERIFICATION DISCLOSURE
As part of the Camp Kesem volunteer process, Camp Kesem National will obtain an
investigative consumer report. The investigative consumer report may include information
regarding your credit worthiness, credit standing, credit capacity, character, general
reputation, personal characteristics or mode of living. The following Consumer Reporting
Agency will prepare the report:
ChoicePoint Services Inc.
1000 Alderman Dr.
Alpharetta, GA 30005
California Notice:
You have the right under Section 1786.22 of the California Civil Code to contact ChoicePoint
during normal business hours to obtain your file for your review. You may obtain such
information as follows:
1. In person at ChoicePoint’s office at the address listed above. You will need to
furnish proper identification prior to receiving your file. You may have someone
accompany you and should inform such person that they will also have to present
reasonable identification. If you want ChoicePoint to disclose to or discuss your
information with this third party, you may be required to provide a written statement
granting ChoicePoint permission to do so.
2. By certified mail, if you make a written request (and provide proper identification)
to have your file sent to a specified addressee.
3. By telephone, if you have previously made a written request and provided proper
identification. ChoicePoint has trained personnel to explain any information that is
furnished to you and to explain any information that is coded.
Rev. 9/10
© 2004 Camp Kesem National. All Rights Reserved. Camp Kesem & the Camp Kesem logo are trademarks of Camp Kesem National.