Camp Kum-Ba-Yah Staff Application Please complete all sections of the application. Incomplete applications will not be accepted. 4415 Boonsboro Rd. Lynchburg, VA 24503 434 384-1755 CampKBY@verizon.net Camp Kum-Ba-Yah does not discriminate in hiring or employment on the basis of race, color, gender, age, religion, national origin, the presence of non-job-related medical condition or handicap, or any other legally protected status. A description of the section goes here. POSITION APPLYING FOR: Please Check One: Unit Leader Associate Unit Leader Other If "other" has been check please fill in position you are applying for: PERSONAL DATA Name First Last Are you 18 or older? Yes No Are you 16 or older? Yes No Address Street Address Address Line 2 City State / Province / Region Postal / Zip Code Antigua and Barbuda Aruba,Bahamas Barbados Belize Canada Cook Islands Costa Rica Cuba Dominica Dominican Republic El Salvador Grenada Guatemala Haiti Honduras Jamaica Mexico Netherlands Antilles Nicaragua Panama Puerto Rico Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Trinidad and Tobago United States Argentina Bolivia Brazil Chile Colombia Ecuador Guyana Paraguay Peru Suriname Uruguay Venezuela Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Faroe Islands Finland France Georgia Germany Greece Hungary Iceland Ireland Italy Latvia Liechtenstein Lithuania Luxembourg Macedonia Malta Moldova Monaco Montenegro Netherlands Norway Poland Portugal Romania San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Ukraine United Kingdom Vatican City Afghanistan Bahrain Bangladesh Bhutan Brunei Darussalam Myanmar Cambodia China East Timor Hong Kong India Indonesia Iran Iraq Israel Japan Jordan Kazakhstan North Korea South Korea Kuwait Kyrgyzstan Laos Lebanon Malaysia Maldives Mongolia Nepal Oman Pakistan Palestine Philippines Qatar Russia Saudi Arabia Singapore Sri Lanka Syria Taiwan Tajikistan Thailand Turkey Turkmenistan United Arab Emirates Uzbekistan Vietnam Yemen Australia Fiji Kiribati Marshall Islands Micronesia Nauru New Zealand Palau Papua New Guinea Samoa Solomon Islands Tonga Tuvalu Vanuatu Algeria Angola Benin Botswana Burkina Faso Burundi Cameroon Cape Verde Central African Republic Chad Comoros Democratic Republic of the Congo Republic of the Congo Djibouti Egypt Equatorial Guinea Eritrea Ethiopia Gabon Gambia Ghana Gibraltar Guinea Guinea-Bissau Cote d'Ivoire Kenya Lesotho Liberia Libya Madagascar Malawi Mali Mauritania Mauritius Morocco Mozambique Namibia Niger Nigeria Rwanda Sao Tome and Principe Senegal Seychelles Sierra Leone Somalia South Africa Sudan Swaziland United Republic of Tanzania Togo Tunisia Uganda Zambia Zimbabwe Country Phone Number ### - ### - #### Are you a US Citizen? Yes No If you are not a citizen, have you the right to work in the US? Yes No (Proof of citizenship and work authorization will be required upon employment in accordance with federal regulations) Address *If different from above Street Address Address Line 2 City State / Province / Region Postal / Zip Code Antigua and Barbuda Aruba,Bahamas Barbados Belize Canada Cook Islands Costa Rica Cuba Dominica Dominican Republic El Salvador Grenada Guatemala Haiti Honduras Jamaica Mexico Netherlands Antilles Nicaragua Panama Puerto Rico Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Trinidad and Tobago United States Argentina Bolivia Brazil Chile Colombia Ecuador Guyana Paraguay Peru Suriname Uruguay Venezuela Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Faroe Islands Finland France Georgia Germany Greece Hungary Iceland Ireland Italy Latvia Liechtenstein Lithuania Luxembourg Macedonia Malta Moldova Monaco Montenegro Netherlands Norway Poland Portugal Romania San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Ukraine United Kingdom Vatican City Afghanistan Bahrain Bangladesh Bhutan Brunei Darussalam Myanmar Cambodia China East Timor Hong Kong India Indonesia Iran Iraq Israel Japan Jordan Kazakhstan North Korea South Korea Kuwait Kyrgyzstan Laos Lebanon Malaysia Maldives Mongolia Nepal Oman Pakistan Palestine Philippines Qatar Russia Saudi Arabia Singapore Sri Lanka Syria Taiwan Tajikistan Thailand Turkey Turkmenistan United Arab Emirates Uzbekistan Vietnam Yemen Australia Fiji Kiribati Marshall Islands Micronesia Nauru New Zealand Palau Papua New Guinea Samoa Solomon Islands Tonga Tuvalu Vanuatu Algeria Angola Benin Botswana Burkina Faso Burundi Cameroon Cape Verde Central African Republic Chad Comoros Democratic Republic of the Congo Republic of the Congo Djibouti Egypt Equatorial Guinea Eritrea Ethiopia Gabon Gambia Ghana Gibraltar Guinea Guinea-Bissau Cote d'Ivoire Kenya Lesotho Liberia Libya Madagascar Malawi Mali Mauritania Mauritius Morocco Mozambique Namibia Niger Nigeria Rwanda Sao Tome and Principe Senegal Seychelles Sierra Leone Somalia South Africa Sudan Swaziland United Republic of Tanzania Togo Tunisia Uganda Zambia Zimbabwe Country Phone Number ### - ### - #### Cell Phone Number ### - ### - #### EDUCATION Please list your education by Years, School, Major, and Degree Obtained WORK HISTORY Provide us with a full record of paid and volunteer employment using a separate page if necessary. Dates Company Name Company Address Phone Number ### - ### - #### Position held and duties performed Dates Company Name Company Address Phone Number ### - ### - #### Position held and duties performed Dates Company Name Company Address Phone Number ### - ### - #### Position held and duties performed CAMP EXPERIENCE Please complete all sections of the application. Incomplete applications will not be accepted. Dates Camp Camp Director Camper or Staff Camper Staff Dates Camp Camp Director Camper or Staff Camper Staff Dates Camp Camp Director Camper or Staff Camper Staff CERTIFICATIONS Please mark which certifications you have or are willing to obtain. Current Red Cross Life-Guard Certificate Yes No Current Red Cross Water Safety Instructor (WSI) Certificate? If yes, please give date and place of certification. Yes No Date & Place of Certification Current certification in First Aid/CPR? Expiration date: Yes No SKILLS: If you have any training, experience, expertise, or certification in any of the following areas, please indicate below. Ratings: 1= Those activities you can organize, teach, and work with competently. 2= Those you can assist in teaching. 3= Those you can participate with some ability. Arts and Crafts Rating 1 Rating 2 Rating 3 Handicrafts Rating 1 Rating 2 Rating 3 Macramé Rating 1 Rating 2 Rating 3 Sketching Rating 1 Rating 2 Rating 3 Weaving Rating 1 Rating 2 Rating 3 Wood Rating 1 Rating 2 Rating 3 Leather Rating 1 Rating 2 Rating 3 Pottery Rating 1 Rating 2 Rating 3 Painting Rating 1 Rating 2 Rating 3 Nature Crafts Rating 1 Rating 2 Rating 3 Tye Dyeing Rating 1 Rating 2 Rating 3 Painting Rating 1 Rating 2 Rating 3 Waterfront Rating 1 Rating 2 Rating 3 Performing Arts Rating 1 Rating 2 Rating 3 Song Leading Rating 1 Rating 2 Rating 3 Dance Rating 1 Rating 2 Rating 3 Storytelling Rating 1 Rating 2 Rating 3 Acting (skits) Rating 1 Rating 2 Rating 3 Mime Rating 1 Rating 2 Rating 3 Clowning Rating 1 Rating 2 Rating 3 Environmental Activities Rating 1 Rating 2 Rating 3 Outdoor Cooking Rating 1 Rating 2 Rating 3 Music Piano Guitar Singing Ropes Course Low Elements High Elements Languages Please list languages QUESTIONS FOR PERSONAL REFLECTION After thoughtful consideration, please answer the following questions to the best of your ability. Use additional paper if necessary. 1. Tell us briefly about yourself and include detail regarding any experience or training you have had that has prepared you for a position at Camp Kum-Ba-Yah? 2. What contribution do you feel you will make to the Kum-Ba-Yah camp program? 3. What contributions do you think a well-run day camp can make in the lives of the children it serves? Do you prefer to work with a specific age group? Yes No If yes, please request age. REFERENCES: Please ask two references (not personal friends or relatives) who can attest to your professional or work performance to complete the attached reference forms and return them to us by fax or mail personally Since your last date of employment, have you been convicted of a crime or sex offense involving a minor? Yes No Have you read and do you understand the information contained in the Staff Application Information and Job Description? Yes No Are you willing to accept the conditions outlined? Yes No I understand that in the event of my employment by Camp Kum-Ba-Yah, Inc., it shall be sufficient cause for dismissal if any of the information I have given in this application is false or if I have failed to give any information herein requested. * First Last Date 1 2 3 4 5 6 7 8 9 10 11 12 MM / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 DD / 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 YYYY RELEASE OF INFORMATION I authorize, without liability, investigation of all statements in this application. I expressly waive all provisions of law prohibiting any physician, person, hospital or other institution that has or may hereafter attend or furnish me with treatment from disclosing to Camp Kum-Ba-Yah, Inc. any knowledge or information hereby acquired. I authorize all schools which I attended and all previous employers to furnish to Camp Kum-Ba-Yah, Inc. my record, reason for leaving and all information they may have concerning me and I hereby release them and Camp Kum-Ba-Yah, Inc. from all liability for any damage whatsoever arising therefrom. I authorize those references listed with whom I am acquainted to furnish Camp Kum-Ba-Yah, Inc. with information used in connection with the evaluation of my qualifications as a prospective employee. This authorization will continue for a period of one year from the below date. First Last 1 2 3 4 5 6 7 8 9 10 11 12 MM / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 DD / 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 YYYY Image Verification Please enter the text from the image: [Refresh Image] [What's This?] Powered byEMF Web Form Report Abuse
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