Staff Registration Form

* indicates a required field 
Staff Information
*Name:  First    Middle   Last
*Address :  
*City:        State      Zip
*Phone:      Alt. Phone    Email
*School/Business Address  
 *Phone:      Fax    Email
*Sex:   Male       Female
*Date of Birth:  (mm/dd/yyyyy)
*Birth Country:  
*Ethnicity:  
*Are you:   International Adoptee       Transracial Adoptee       Both?
*Adoption Agency:   Holt-USA       Other       Not adopted
*I will be 18 years or older & a high school graduate at the time of camp:      
*Can you perform the essential functions of the job for which you have applied with or without reasonable accommondation?      
*Camp t-shirt size
Youth: S       M       L
Adult: S       M       L      XL       XXL
References(Please list three reference, not relatives)
Name:   Email:   Phone:  
Address:  
City:   State:   Zip:  
Name:   Email:   Phone:  
Address:  
City:   State:   Zip:  
Name:   Email:   Phone:  
Address:  
City:   State:   Zip:  
Work&/or Volunteer Experience Related to Children & Teens
Dates Employer/Supervisor Address Responsibilities Phone/Email
Camp Experience
Dates Camp&Director Location Camper, Staff or Other
Certifications( Health/Safety)
Please mark those for which you hold current certification:
CPR       Lifeguard       First aid       Nursing       Other
Camp Program Skills
In the following list put a "T" before those activities you can organize and teach as an expert, and an "A" for those activities in which you can assist. Put a "C" after those in which you have current certification.
Arts/Crafts ceramics/pottery       drawing/painting       leather craft       metal work 
photography       woodworking       Other
Dance Other
Drama clowning       theater       Other
Music singing         instruments ->list
Sports/Fitness martial arts ->list       Other
Waterfront Activities canoeing       kayaking       rafting       rowing 
swimming       Other
Miscellaneous cooking    adoption issues       identity issues       race issues 
writing     storytelling              team building        leadership development 
poetry     foreign language ->list     Other
Please answer the following questions
*Why do you want to be a part of Holt Camp?
                                 
*What contributions do you think that you can make at camp?
                                 
*What contributions do you think a well-run camp can make to children?