Personal Information-

First Name Middle Name Last Name Suffix

Street Address City

State ZIP E-mail A value is required.

Home Phone Number Mobile Number

Highest Level of Education Major/ Degree/ Certificate

School GPA

T-Shirt Size Occupation Legally Employable in US? Yes or No

If military, would take: Leave Permissive TDY Both

Scouting Experience-

Do you have prior Scouting experience? Yes No

Currently Registered With: Pack Troop Crew Post Ship Position in Unit Council:

Have you ever served on resident camp staff (including CIT)?
Camp: Year: Position(s):
Camp: Year: Position(s):
Camp: Year: Position(s):

Highest Rank Attained <1ce>

OA Member? Yes No Lapsed <0> OA Honor Level Ordeal Brotherhood Vigil NA <0>Offices Held in OA

How many times have you attended a BSA Summer Camp? <10sp>How many different camps?

Number of days & nights of outdoor camping experience: 0-20 21-50 51-100 over 100

I have participated in (choose all that apply by holding crtl button to select multiple):
None National/ World Jamboree Florida Sea Base Northern Tier OA High Adventure Philmont None Day Camp Staff District Camporee Staff Council Camporee Staff Conclave Staff Woodbadge/ NYLT Staff None Youth Protection Woodbadge NYLT Den Chief Training Leader Specific Training None Weather Hazards IOLS WOLS

BSA National Camp School Training Completed:
(Indicate Course Attended, Certification Received and Expiration Date)

Are You Currently Trained in CPR and/or First Aid by the American Red Cross?

When does you CPR training expire? EMT or Advanced First Aid Cert. Expiration Date:

SELF-EVALUTATION

Give additional details of your Qualifications

1st Choice Position Desired None Archery Counselors (Min Age 18) Boating/ Skiing/wakeboarding Counselor (Min. Age 18) Canoeing +/or Rowing Counselors Climbing Counselor Fishing Counselor Handicraft Counselor High Adventure Huskanaw Counselor Natural History Counselor Nature Counselor Rifle +/or Shotgun Counselor Scoutcraft Counselor Sm. +/or Lg. Boat Sailing Counselor Swimming +/or Lifesaving Counselor Program Director Scoutmaster Program Director Aquatics Director (Min. Age 21) Climbing Director (Min. Age 21) Handicraft Director High Adventure Director (Min. Age 21) Huskanaw Director Natural History Director (Min. Age 21) Nature Director Pool Director (Min. Age 18) Scoutcraft Director Shooting Sports Director (Min. Age 21) Waterfront Director (Min. Age 18) Business Manager (Min. Age 18) Commissioner (Min Age 21) Quartermaster Health & Safety Officer (Min. Age 21) Chaplain (Min. Age 21) Head Cook (Min. Age 18) Assistant Cook (Min. Age 18) Dining Hall Steward (Min. Age 18) Dining Hall Staff Trading Post Clerk Trading Post Manager (Min Age 18)

2nd Choice Position Desired None Archery Counselors (Min Age 18) Boating/ Skiing/wakeboarding Counselor (Min. Age 18) Canoeing +/or Rowing Counselors Climbing Counselor Fishing Counselor Handicraft Counselor High Adventure Huskanaw Counselor Natural History Counselor Nature Counselor Rifle +/or Shotgun Counselor Scoutcraft Counselor Sm. +/or Lg. Boat Sailing Counselor Swimming +/or Lifesaving Counselor Program Director Scoutmaster Program Director Aquatics Director (Min. Age 21) Climbing Director (Min. Age 21) Handicraft Director High Adventure Director (Min. Age 21) Huskanaw Director Natural History Director (Min. Age 21) Nature Director Pool Director (Min. Age 18) Scoutcraft Director Shooting Sports Director (Min. Age 21) Waterfront Director (Min. Age 18) Business Manager (Min. Age 18) Commissioner (Min Age 21) Quartermaster Health & Safety Officer (Min. Age 21) Chaplain (Min. Age 21) Head Cook (Min. Age 18) Assistant Cook (Min. Age 18) Dining Hall Steward (Min. Age 18) Dining Hall Staff Trading Post Clerk Trading Post Manager (Min Age 18)

3rd Choice Position Desired None Archery Counselors (Min Age 18) Boating/ Skiing/wakeboarding Counselor (Min. Age 18) Canoeing +/or Rowing Counselors Climbing Counselor Fishing Counselor Handicraft Counselor High Adventure Huskanaw Counselor Natural History Counselor Nature Counselor Rifle +/or Shotgun Counselor Scoutcraft Counselor Sm. +/or Lg. Boat Sailing Counselor Swimming +/or Lifesaving Counselor Program Director Scoutmaster Program Director Aquatics Director (Min. Age 21) Climbing Director (Min. Age 21) Handicraft Director High Adventure Director (Min. Age 21) Huskanaw Director Natural History Director (Min. Age 21) Nature Director Pool Director (Min. Age 18) Scoutcraft Director Shooting Sports Director (Min. Age 21) Waterfront Director (Min. Age 18) Business Manager (Min. Age 18) Commissioner (Min Age 21) Quartermaster Health & Safety Officer (Min. Age 21) Chaplain (Min. Age 21) Head Cook (Min. Age 18) Assistant Cook (Min. Age 18) Dining Hall Steward (Min. Age 18) Dining Hall Staff Trading Post Clerk Trading Post Manager (Min Age 18)

New Applicants. Answer the following: Why do you want to be on Camp Staff?

Other Information

Describe your hobbies & special interests:

Describe any military service/ experience:

Have you ever been convicted of a felony? Yes No space Misdemeanor? Yes No
If yes, explain:

Employment
Company/Employer Position Held Dates Phone

Company/Employer Position Held Dates Phone
Have you ever been discharged or asked to resign from any job? Yes No
If yes, why?

References
Scouting: Name Phone Number Relationship

Scouting: Name Phone Number Relationship

School: Name Phone Number Relationship

Employer: Name Phone Number Relationship

Other: Name Phone Number Relationship

Availability/ Compensation

I am available/ interested in working:
Base Camp: Staff Week Boy Scouts Cub Scouts Close-out
James River Adventure Base:
Staff Week Canoe Trek Fish Camp James River Experience John Smith Program Sail Hampton Roads

Camp Dates of Operation are 6/26/11- 8/14/11 Dates you are available:

Seeking Compensation Via:

Money

Community Service Hours

Internship Credit

Thank You Letter

By clicking here you certify that all the information you have provided is correct. Please make a selection.