Camp Sign 2019 Counselor Application Survey

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* 1. Position for which you are applying: Indicate your first and second choices.

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* 2. Last Name:

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* 3. First Name:

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* 4. Birth Date (MM/DD/YY):

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* 5. Age:

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* 6. Gender:

Male

Female

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* 7. Address:

Address *

Address 2 *

City/Town *

State/Province *

ZIP/Postal Code *

Country

Email Address *

Phone Number *

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* 8. T-Shirt Size (Unisex):

XXL

XXXL

Other (please specify)

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* 9. Status of Hearing Loss:

Deaf

Hard of Hearing

Hearing

Other (please specify)

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* 10. Method of Communication:

American Sign Language

Signed Exact English

Spoken English

Other (please specify)

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* 11. Expressive Skills:

	Excellent	Good	Fair	N/A
American Sign Language (ASL)	American Sign Language (ASL) Excellent	American Sign Language (ASL) Good	American Sign Language (ASL) Fair	American Sign Language (ASL) N/A
Signed Exact English (SEE)	Signed Exact English (SEE) Excellent	Signed Exact English (SEE) Good	Signed Exact English (SEE) Fair	Signed Exact English (SEE) N/A
Spoken English	Spoken English Excellent	Spoken English Good	Spoken English Fair	Spoken English N/A

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* 12. Receptive Skills:

	Excellent	Good	Fair	N/A
American Sign Language (ASL)	American Sign Language (ASL) Excellent	American Sign Language (ASL) Good	American Sign Language (ASL) Fair	American Sign Language (ASL) N/A
Signed Exact English (SEE)	Signed Exact English (SEE) Excellent	Signed Exact English (SEE) Good	Signed Exact English (SEE) Fair	Signed Exact English (SEE) N/A
Speech Comprehension	Speech Comprehension Excellent	Speech Comprehension Good	Speech Comprehension Fair	Speech Comprehension N/A
Lipreading	Lipreading Excellent	Lipreading Good	Lipreading Fair	Lipreading N/A

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* 13. Camp Skills (OPTIONAL)

	I can organize and teach this as an expert	I have a related certification (you MUST attach a copy)	N/A
Archery	Archery I can organize and teach this as an expert	Archery I have a related certification (you MUST attach a copy)	Archery N/A
Arts and Crafts	Arts and Crafts I can organize and teach this as an expert	Arts and Crafts I have a related certification (you MUST attach a copy)	Arts and Crafts N/A
Drama	Drama I can organize and teach this as an expert	Drama I have a related certification (you MUST attach a copy)	Drama N/A
Field Sports	Field Sports I can organize and teach this as an expert	Field Sports I have a related certification (you MUST attach a copy)	Field Sports N/A
Fitness and Exercise	Fitness and Exercise I can organize and teach this as an expert	Fitness and Exercise I have a related certification (you MUST attach a copy)	Fitness and Exercise N/A
Hiking	Hiking I can organize and teach this as an expert	Hiking I have a related certification (you MUST attach a copy)	Hiking N/A
Horseback Riding	Horseback Riding I can organize and teach this as an expert	Horseback Riding I have a related certification (you MUST attach a copy)	Horseback Riding N/A
Karate	Karate I can organize and teach this as an expert	Karate I have a related certification (you MUST attach a copy)	Karate N/A
Lake Activities	Lake Activities I can organize and teach this as an expert	Lake Activities I have a related certification (you MUST attach a copy)	Lake Activities N/A
Leadership Training	Leadership Training I can organize and teach this as an expert	Leadership Training I have a related certification (you MUST attach a copy)	Leadership Training N/A
STEM (Science, Technology, Engineering, Math)	STEM (Science, Technology, Engineering, Math) I can organize and teach this as an expert	STEM (Science, Technology, Engineering, Math) I have a related certification (you MUST attach a copy)	STEM (Science, Technology, Engineering, Math) N/A
Swimming	Swimming I can organize and teach this as an expert	Swimming I have a related certification (you MUST attach a copy)	Swimming N/A
Team Building	Team Building I can organize and teach this as an expert	Team Building I have a related certification (you MUST attach a copy)	Team Building N/A
Yoga	Yoga I can organize and teach this as an expert	Yoga I have a related certification (you MUST attach a copy)	Yoga N/A

Other (please specify)

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* 14. Additional Certifications:

	YES	N/A
Cardiopulmonary Resuscitation (CPR)	Cardiopulmonary Resuscitation (CPR) YES	Cardiopulmonary Resuscitation (CPR) N/A
First Aid	First Aid YES	First Aid N/A
Water Safety Instruction or Lifeguard	Water Safety Instruction or Lifeguard YES	Water Safety Instruction or Lifeguard N/A

Other (please specify)

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* 15. Essay #1 : What kind of role model do you think you would be? How will you serve as this role model?

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* 16. Essay #2: Write a brief biographical sketch, including specialized training in camping, and experience or training in other fields related to the position(s) for which you are applying.

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* 17. Education Information:

Name of School:

City:

State:

Diploma or Major:

Type of Degree:

Year of Graduation:

Years attended:

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* 18. Education Information continued:

Name of School:

City:

State:

Diploma or Major:

Type of Degree:

Year of Graduation:

Years attended:

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* 19. Education Information continued:

Name of School:

City:

State:

Diploma or Major:

Type of Degree:

Year of Graduation:

Years attended:

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* 20. Education Information continued:

Name of School:

City:

State:

Diploma or Major:

Type of Degree:

Year of Graduation:

Years attended:

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* 21. Employment and Camp Staff Experience: List most recent position first.

Start Date:

End Date:

Position:

Business/Camp Name and Location:

Supervisor's Name:

Supervisor's Email and/or Phone Number:

Description of Job Responsibilities:

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* 22. Employment and Camp Staff Experience:

Start Date:

End Date:

Position:

Business/Camp Name and Location:

Supervisor's Name:

Supervisor's Email and/or Phone Number:

Description of Job Responsibilities:

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* 23. Employment and Camp Staff Experience:

Start Date:

End Date:

Position:

Business/Camp Name and Location:

Supervisor's Name:

Supervisor's Email and/or Phone Number:

Description of Job Responsibilities:

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* 24. References: List three people who know you and your abilities. Do not include family members!

Reference 1 First and Last Name:

Reference 1 Relationship:

Reference 1 Email Address:

Reference 1 Phone Number:

Reference 2 First and Last Name:

Reference 2 Relationship:

Reference 2 Email Address:

Reference 2 Phone Number:

Reference 3 First and Last Name:

Reference 3 Relationship:

Reference 3 Email Address:

Reference 3 Phone Number:

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* 25. I certify to the best of my knowledge that the information given in this application is true and correct, and that I will follow the policies of Camp Sign.

Full Name:

Today's Date (MM/DD/YY)