Follow-Up Counselor Application

Fields marked with an* are required.

First Name*

Last Name*

Email*

Previous Employment

(List most recent employment first)

Employer

Supervisor

Supervisor Phone

City

State

Position

Dates Employed

Reason for Leaving

Job 2

Employer

Supervisor

Supervisor Phone

City

State

Position

Dates Employed

Reason for Leaving

Job 3

Employer

Supervisor

Supervisor Phone

City

State

Position

Dates Employed

Reason for Leaving

References

(Do not list relatives or personal friends)

Full Name

Occupation

Phone

How does he/she know you?

Reference 2

Full Name

Occupation

Phone

How does he/she know you?

Reference 3

Full Name

Occupation

Phone

How does he/she know you?

Certifications

Please list your current certifications, include the Type (ex. Lifeguard, CPR, EMT), the certifying Organization (ex. Red Cross, YMCA, Wilderness Medical Associates) and the Expiration Date.

Type

Organization

Expiration Date

Certification 2

Type

Organization

Expiration Date

Certification 3

Type

Organization

Expiration Date

As a staff member, you will be giving up a great deal of privacy and comfort, working long and demanding hours, adhering to camp policies which may be limiting and not necessarily reflect your way of living. Do you see any problem complying with this type of lifestyle?*

Yes
No

Please explain:

I understand that staff members are not permitted to have their cell phones with them while on duty and phones may only be used during designated time-off.*

Yes
No

Please explain:

Do you have any physical limitations that would hamper your ability to perform the job applied for?*

Yes
No

Please explain:

Do you have a current driver's license?*

Yes
No

Have you ever been arrested, charged, or convicted of violating any laws?*

Yes
No

Please provide details:

(A "yes" answer does not automatically disqualify you from employment. The date, nature of the offense, and the job for which you are applying will all be considered.)

Have you ever been investigated, accused, or convicted of sexually or physically abusing a child?*

Yes
No

Please provide details:

Kingsley Pines Camp is drug, alcohol, and smoke free. Does this pose a problem for you?*

Yes
No

Please explain:

Authorization*

I authorize the investigation of any or all statements contained in this application and also authorize any person, school, law enforcement agency, current employer, past employers, and organizations named in this application to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements. I hereby declare that the information provided by me in this application for employment is accurate and complete to the best of my knowledge. I understand that any falsification or misrepresentation in this application is cause for discharge.

I have read, understand, and consent to these statements by electronically submitting this application.

Email

This field is for validation purposes and should be left unchanged.

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Previous Employment

Job 2

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References

Reference 2

Reference 3

Certifications

Certification 2

Certification 3