Staff Application

In accordance with the Children's Online Privacy Protection Act, a person must be 13 years of age or older to complete and submit this form. Please Fill Out & Complete All fields. Use The Pointer to Move Between Fields.

Personal Information

Name:

Permanent Address

Street & Number:

City:

State:

Zip:

College Address

Street & Number:

City:

State:

Zip:

Home Phone:

Cell Phone:

College Phone:

E-Mail:

Date of Birth:

Marital Status:

Single

Married

Camp Age Children?:

Yes

Child's Name:

Age:

School:

Grade:

Child's Name:

Age:

School:

Grade:

Child's Name:

Age:

School:

Grade:

Applicant's Mount Tom History

Camper:

Yes

If Yes, Years Attended:

(i.e. 2001-2005)

Staff:

Yes

If Yes, Years Worked:

Work History

Please list most recent first

Job 1

Dates:

Position:

Employer Name:

Address:

Telephone:

Reason for leaving:

Job 2

Dates:

Position:

Employer Name:

Address:

Telephone:

Reason for leaving:

Job 3

Dates:

Position:

Employer Name:

Address:

Telephone:

Reason for leaving:

Job 4

Dates:

Position:

Employer Name:

Address:

Telephone:

Reason for leaving:

Position Interest

If Specialist, Your Specialty:

(hold down CTRL key to select multiple items)

If you have taught other activities, please list here:

Dates Available

From:

To:

Please explain your interest in this position for the upcoming camp season and how you can make a positive impact on our program. Discuss your previous experiences that are relevant to this position. Please share with us how you heard about Mount Tom.:

Applicant's Other Camp Experience

Name of Camp:

Year(s):

Location:

Camper or Staff?:

Name of Camp:

Year(s):

Location:

Camper or Staff?:

Name of Camp:

Year(s):

Location:

Camper or Staff?:

Educational Background

Grad School

Name of School:

Degree:

Area of Concentration:

Date of Degree:

College/Univ

Name of School:

Year:

Major:

Degree:

Date of Degree:

High School

Name of School:

Grade:

References & Record

Please list people who know your character, strengths, work ethic, personality, etc. (other than family).

Reference 1

Name of Reference:

Phone:

Address:

Relationship to applicant:

Reference 2

Name of Reference:

Phone:

Address:

Relationship to applicant:

Reference 3

Name of Reference:

Phone:

Address:

Relationship to applicant:

Harassment

The camp's policy is to prohibit all forms of harassment by our employees. This includes sexual, racial, religious, and other forms of harassment. Have you ever been accused of harassment of any person including, but not limited to workplace harassment? (Note: a prior accusation or conviction is not an automatic bar to employment. The type of conviction or accusation and when it occurred will be evaluated by the camp before any decision is made).

Harassment:

Yes

If yes explain:

Criminal Record

Have you ever been convicted of a crime, other than a minor traffic offense? If yes please describe. (Note: a prior conviction is not an automatic bar to employment. The type of conviction or accusation and when it occurred will be evaluated by the camp before any decision is made).

Criminal Record:

Yes

If yes explain:

Authorization: *

I agree

I authorize investigation of all statements herein, including any checks of criminal records, and release the camp and all others from liability in connection with same. I understand that, if employed, I will be an at-will employee unless there is an agreement or law which alters that status. Furthermore, I understand that any agreement must be in writing and signed by the designated camp official. I also understand that untrue, misleading, or omitted information herein or in other documents completed by the applicant may result in dismissal, regardless of the time of discovery by the camp.