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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?

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