Arlene Streisand's Summer Camp Services Application
P.O. Box 196, Jericho, NY 11753
1-800-443-6428 • • • 516-433-8033 • • •Fax: 516-933-7949



Note- There are some areas in the application below where scrolling may be necessary
Name:
SS#
E-Mail:
Present Mailing Address:
City:
State
Zip
Telephone:
(area code required)
Permanent Address:
City:
State
Zip
Permanent E-mail
Telephone: (area code required)
Height:
Weight: lbs.
Sex
M F
Date of Birth (MM/DD/YY)
Age as of next July 1st
Do you smoke?
Yes No
Are you married?
Yes No
Do you have any children? Yes No
If yes, please explain.
Have you ever been arrested or convicted of a crime? Yes No
If yes, please explain.
   
Education  
 College(s)
 Major Subjects
 Years
 Degree Granted
       
   
Past Employment List previous two summers or years.
Dates
(MM/DD/YY)
Employer
Phone
Nature Of Work
       
Camp Experience List previous two summers or years.
Dates
(MM/DD/YY)
Camp
Director
Location
Phone
   
Are you available from approximately June 15 to August 18? Yes No
What type of position do you want at camp? If specialties, list in order of preference:
 

In the following list, select numeral:
"1" before those activities you can organize and teach as an expert
"2" for those activities in which you can assist in teaching
"3" for those which are just your hobby.
(Only indicate those areas which apply to you).
Please Note that scrolling to the right may be necessary to see all the options.
Arts & Crafts Dance Nature Sports (cont) Registered Nurse
Basketry Acrobatic Animals Riflery Pediatrics
Batik Ballet Astronomy NRA Instructor R.N. (date, state)
Candlemaking Tap Birds Skating Miscellaneous
Ceramics Folk Conservation Soccer Audio/Visual Equip
Copper Enamel Jazz Farming Softball Bike Repair
Jewelry Modern Flowers Street Hockey Campfire Programs
Leather Work Aerobics Forestry Tennis Evening Programs
Metal Work Dramatics Gardening Track & Field Indian Lore
Mosiac Tile Creative Insects Trampoline Language
Nature Crafts Play Directing Rocks & Minerals Volleyball Newspaper
Painting Skits and Stunts Trees & Shrubs Weight Training Photography
Pottery Sound/Light Board Weather Free Weights Darkroom Instruction
Silkscreen Set Design Sports Universal Radio/Electronic
Sculpture Costuming Archery Wrestling Storytelling
Silver Work Gymnastics Badmitton Roller Blading Computer Science
Sketching Beam Baseball Roller Hockey Bridge
Stained Glass Bars Basketball Waterfront Activities   Juggling
Weaving Floor Bicycling Canoeing Circus
Wood Carving Vault Boxing Diving Secreterial
Wood Working Advanced Skills Fencing Kayaking Security Guard
Rocketry Kitchen/Laundry Field Hockey Lifesaving Nanny
Cartooning Food Preparation Fishing Motorboat Driving Equestrian
Adventure Cleanup/Maintenance Golf Rowing English
Backpacking Food Service Informal Games Sailing Western
Mountain Biking Chef Jogging Scuba  
Camping Skills Steward Karate Swimming  
Hiking Music Lacrosse Water Polo  
Orienteering Bugle   Water Skiing  
Outdoor Cooking Drums   Windsurfing  
Overnight Camping Guitar   Wakeboarding  
Rock Climbing Instrument (List)      
Ropes Course Song Leader      
  Piano Accompanist      
 
Do you currently hold any American Red Cross instructor certificates? Yes No
(please enter EXPIRATION dates in MM/DD/YY format)
     
WSI  CPR
Canoeing First Aid
Sailing Life Guard
EMT Certified Rescue Aide
Life Guard Instruction/Trainer First Aid Responder
Other    
   
Any physical defects or diseases affecting your ability to perform your job? Yes No
   

If you have a friend or a relative interested in camp work, please fill out below:

Name
Telephone Number (area code required)
Address
   
Do you own a car? Yes No
Would you drive to camp? Yes No
Would you be willing to take passengers? Yes No
 
PLEASE COMPLETE
(email additional information if necessary by clicking here)
You MUST answer the questions below:
1) Outline your training and/or experience in the activity areas you wish to work. Include any other biographical data such as family, travels, camping experiences, etc., which might have a bearing in this application. Be sure to include any competitive or varsity experiences:



2) Why do you want to be a camp counselor? What contribution do you think you can make at camp? What qualities or characteristics do you feel you have which will enable you to be an effective counselor? Do you have any leadership skills or special abilities?

   
3) Please indicate first choice below:
Select Age Group of Campers you prefer for cabin duty:
5-7 7-9 9-11 13-15 15 & over Flexible
 
Select Age Group you are best equipped to teach
5-7 7-9 9-11 13-15 15 & over Flexible
   

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