Return Counselor Application

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Date of Application:
First Name
Last Name

Social Security No.


Your Current Mailing Address (School)
Street Address
your Address cont'd
City
State
Zip
	Current Phone
	Cell Phone
Parents/Permanent Address
Permanent Street Address:
City
State
Zip
	Perm. Phone

Personal Data

Date of Birth		Age July 1



Since last summer, have you worked with children as a Counselor, Supervisor, or Instructor? If so when and where?
Since last summer, any additional experience as camper or camp counselor?


YOUR HEALTH:
Is your general health good?
	Any physical impairments?

Briefly describe any injury or health condition occurring since last summer which may affect your employment as a counselor:

Your Activity Skills, Qualifications & Preferences:

All staff members, in addition to teaching an activity, will live in a cabin with 8-12 campers and a co-counselor.
Time off schedules are arranged so that one counselor is always in the cabin.
What age campers would you prefer to have in your cabin?
Wranglers? Cowboys? Tophands? Advanced Campers?

Which term(s) are you interested in working this summer?

What would be your preference of activity to teach this summer and why?

Are you interested in spending your summer doing or contributing in any of the following? (Y or N)

Campfires - games & songs	Baby Sitting - staff children	First Aide/Nurse	Office Help
Photography	Camp newspaper	Camp Songs	Video Yearbook
Musician	Teach Sunday School	Camp Website	Evening program

If yes, please explain:

Do you have any special talents, certifications, hobbies or skills not mentioned above?

Personal & Character Information

Have you ever been fired from a Job?
Do you smoke?
Do you use alcohol?
Do you use illegal drugs?
Have you ever been arrested?
Have you ever been accused or convicted of a crime?
Ever been accused of a crime involving a child?

Please use the space below to explain any of the above affirmative answers: While such a response does not automatically disqualify you from employment, it will be an important factor in the rehiring process.

Emergency Contact Information:
Person to notify in event of an emergency and their relation to you?
street address
city, state, zip
phone

Personal History

Briefly describe any changes in your home, personal or school life since last summer. Why do you wish to return for another summer.

A counseling position at Camp La Junta involves long hours of intense interaction with young boys and a dedication to the principles of excellence which have been established over the past 80 years. La Junta's standards require that a counselor possess a positive outlook as well as high levels of responsibility, maturity, good judgment and a sincere concern for and patience with young boys. Counselors must also expect much physical activity and complete adherence to camp policies and procedures. Most of all, counselors are expected to work at all times to ensure that each boy's summer is successful.

I certify that to the best of my knowledge the submitted information is true and correct and that I have read and agree with La Junta's stated purpose, goals, philosophies and policies.

In submitting this form, I agree to allow La Junta to perform any and all necessary reference, employment and criminal background checks which they deem necessary to confirm my history, qualifications and suitability for employment.

Signature:

Email Address: