Dates of Camp are July 2nd to August 16th 2012.
For mandatory training dates click here

Applicant’s name:

First Last

Nickname

Gender

Male      Female

Marital Status

Single Married Divorced Widowed

Social Security #:

Driver’s License # (Pls mail in a copy)

Home address:

Home Phone #:

Work Phone #

Cell Phone #:

E-mail address:

Will you be at least 18 years old before the start of camp?
No Yes  
If no, please provide the following:

Mother’s Cell #   
Mother’s Work #
Father’s Cell #    
Father’s Work # 

Do you own a car? No Yes
If Yes, pls provide License Plate #.

Would you like to work pre-camp to help set up?   If yes earliest date available

Staff T-Shirts

We Provide Staff T-Shirts. Please check which size you require:S M L XL XXL XXXL

^{High School}

^College

^{Graduate School}

^Institution

^Major/Minor

^Degree

^{Year of Graduation}

^{Current Year}

^{N/A Freshman Sophomore Junior Senior Graduated}

^{N/A Freshman Sophomore Junior Senior Graduated}

Please Check all that apply: I am a full time student ; I am a part-time Student
                                         I am employed full time  ; I am employed part-time

Work History: Please list your most recent employment especially in camping or involving children. (You may use the spaces below to indicate volunteer work also.)

 If applicable, What type of job do you currently have?                                

Name of Employer

Address of Employer

Phone # of Employer

Supervisor’s Tel #

Previous Employment Details:

^{Name of Employer:}

^{Dates of Employment}

^{Reason for Leaving}

^{Contact Person}

^{Phone #:}

^{Check here if this was a volunteer position:}

^{Name of Employer:}

^{Dates of Employment}

^{Reason for Leaving}

^{Contact Person}

^{Phone #:}

^{Check here if this was a volunteer position:}

^{Name of Employer:}

^{Dates of Employment}

^{Reason for Leaving}

^{Contact Person}

^{Phone #:}

^{Check here if this was a volunteer position:}

REFERENCES: Reference form can be downloaded by clicking here. (if you require a copy of Adobe Acrobat Reader, please click on the icon below.) Reference forms should be filled out by former or present employers, teachers or supervisors and not by friends, relatives or neighbors. (3 are required)

Name

School/Company/Org

Phone

Relationship

1.

2.

3.

Have you had any camping experience either as a camper or staff person? Give dates, name and location of the camp and your role (if a staff member)     

Do you have a teaching degree? No Yes If yes, Please indicate the type of certification you have:

Issuing State

Date issued

Please rate yourself on the following qualities:
10=excellent, 9=very good, 8=Good, 7=Fair

Ability to follow instructions

10 9 8 7

Sense of humor

10 9 8 7

Commitment/loyalty

10 9 8 7

Patience

10 9 8 7

Maturity

10 9 8 7

Leadership

10 9 8 7

Team Work

10 9 8 7

Personal Statements: (Attach additional sheets if necessary. Please attach a resume if you have one)

1. Describe yourself and your strongest qualities.

2. What experience has prepared you most for working with children?

3. Why do you want to work with special needs children and what, if any, experience have you had with them?

4. What is your most important accomplishment?

5. Describe what you think a successful camp experience would be for a child with special needs

6. Please describe your hobbies, interests and any clubs or organizations in which you participate.

Position You are applying for (select all for which you would like consideration):

Junior counselor (high school students)
Preferred age group: 3-5   6-7   8-9   any age group

General Counselor (undergraduate college students and college graduates)
Preferred age group: 3-5   6-7   8-9   10-11  12-15   any age group

Specialist (College graduates or graduate students with knowledge and skills in one of the following areas are hired as specialists. Please check any areas you feel you could lead) sports;  arts & crafts;  music;  nature/science; dance;
 drama;  cooking;  computers;  photography;  bicycle riding;  tennis;
 initiative/team building activities;  life/job skills

Academic Specialist (must be certified special education teacher in the State of New Jersey) Preferred Age Group: 3-5 6-11 12-15 Any Age

Social Skills Specialist (Must have appropriate certification to run social skills groups with children. Social worker, learning consultant, psychologist, guidance counselor or professional counselor are some examples of professionals that qualify.)

Assistant Supervisor (college graduate with relevant experience)

Supervisor (Education degree preferred or relevant degree. Must have experience working with special needs children)

Occupational Therapist (degree in OT; proper licensure and certification required. Please show License # below)

Speech Therapist (degree in Speech Therapy; proper licensure and certification required. Please show License # below)

Not Sure (will discuss if an interview is granted)

Please List your Therapist License #

Certification

Date Issued

Expiration Date

WSI

Lifeguard

CPR

First Aid

RTE

EMT

AED

Epi-Pen

RN

Other (Pls Specify)

Have you ever been convicted of a crime or misdemeanor other than a minor traffic violation? No Yes If yes, please explain.

Camp Dates for 2012: July 2nd-August 16th (Staff training / orientation takes place during the week of June 24) Do you have any conflicts with these dates? No Yes If yes, please explain.

How did you hear about Harbor Haven? Did someone who works or worked at Harbor Haven refer you? Yes No If yes please state who:

Are there any health concerns, allergies or medications that you would like us to be aware of? Yes No If yes, please describe

Staff may be required to be a bus/van counselor, if needed. There is additional salary for this. Are you willing to be a bus counselor if needed? No Yes If no, please explain

Please read the following carefully.
1.  By checking this box , I am giving authorization to Harbor Haven to do a full background search and reference check.
2.  By checking this box , I certify that all the statements and information in this application are accurate and complete, and I understand that any employment offer is based upon the accuracy of this information. If I am hired for a position at Harbor Haven, I understand that any false statements, omissions or inaccuracies of this application may be cause for dismissal. Please insert today’s Date: and write your full name: