Junior Counselor Application Form

Licking Valley Day Camp

Mail to:

GS PAC P.O. Box 988 Florence, KY 41022 ATTN: Day Camp

Name: ______________________________________________________
Last

Troop #: _____________

First

Address: ____________________________________________________
City: _____________________________________________
Age: _______

County: ______________

St: ______

DOB: __________ Home Phone: _______________

Zip: ____________

Cell Phone: ________________

Email Address: _______________________________________________________________________

Parent/Guardian 1

Name: ____________________________________________________________
Last

Cell Phone: __________________________

Parent/Guardian 2

First

Email: ________________________________________

Name: ____________________________________________________________
Last

Cell Phone: __________________________

First

Email: ________________________________________

Education and Training

School: _____________________________________________
Have you ever attended Girl Scout camp? _______
Have you ever attend any other camp? _______

Grade (as of Spring 2014): ________

Type: Day

Resident

Where? __________________________________

Training / Certifications (include PA Training information):

Date Received:

_________________________________________________

___________________________

_________________________________________________

___________________________

_________________________________________________
___________________________
Experience (List your volunteer experience with Girl Scouts and other organizations.)
Position:

Organization:

Time Period (from / to dates):

______________________________

________________________

__________

___________

______________________________

________________________

__________

___________

______________________________

________________________

__________

___________

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References
Name: ______________________________________________

Phone: ______________________

Email Address: ___________________________________________________________________

What is your relationship with this person: ____________________________________________
Name: ______________________________________________

Phone: ______________________

Email Address: ___________________________________________________________________

What is your relationship with this person: ____________________________________________
Name: ______________________________________________

Phone: ______________________

Email Address: ___________________________________________________________________

What is your relationship with this person: ____________________________________________
Availability (Check the weeks you are available to work.)
Week 1: June 13 ~ June 17

Week 4: July 5 ~ July 8

Week 2: June 20 ~ June 24

Week 5: July 11 ~ July 15

Week 3: June 27 ~ June 30

Week 6: July 18 ~ July 22

I understand that:
This is an application for a volunteer position at the Licking Valley Day Camp for which there is
no monetary compensation.
Day camp positions will be filled based on need and availability, not based on color, race,
ethnicity, religion, etc. While experience will be considered, there is no guarantee you will get
the position based on previous experience.
I authorize you to check all my educational, personal and references; I further authorize these
references to release to you information that they have about me.
Any misrepresentation, omission, or falsification of any fact from this application or during any
interview will be cause for rejection of this application or dismissal from volunteer services. I
also understand that acceptance for volunteer services are subject to verification of references.

Application Signature: __________________________________________________

Date: ______________

Parent/Legal Guardian Signature: _________________________________________

Date: ______________

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SKILLS/INTEREST LISTING FOR CAMP VOLUNTEER APPLICANTS

Please print or type and return with the Employment Application

Experienced
Adventure/Challenge
Low Ropes Course
High Ropes Course
Climbing Wall
Zipline
Team Building
Archery
Aquatics/Waterfront
Canoeing, lake and river
Lifeguard
Swimming
Sailing/Windsurfing
Fishing
Camping Skills
Fire building
Hiking
Knots/lashing
Orienteering
Outdoor cooking
Wilderness survival
GPS/Geocaching
Backpacking
Leave No Trace
Crafts
Basketry
Candle making
Ceramics/Pottery/Kiln
Jewelry
Nature crafts
Tie-dyeing
Creative Arts
Creative writing
Drawing
Journalism
Painting
Photography
Printmaking
Sketching
Dancing
Ballroom
Folk
Modern
Square

Can Teach/
Certified?

Experienced

Can Teach/
Certified?

(speak, read,

or write)

Language Skills
Sign language
Spanish
Other:
Music
Instrument (please list)
Song leading
Performing Arts
Acting
Choreography
Playwright and/or direction
Script writing
Set design
Skits and stunts
Storytelling
Theatre/drama
Sports
Baseball
Fitness training
Group games
Softball
Volleyball
Nature and Ecology
Aquatic studies
Animals
Astronomy
Birds
Botany
Conservation
Environmental studies
Flora/fauna identification
Forestry
Geology
Ocean ecology
Rocks and minerals
Star gazing
Trail leading
Trails and signs
Trees and shrubs
Weather
Wildlife

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