CAMP PINECLIFFE
Staff Application Form
Harrison, ME 04040
Susan R. Lifter, Director
Winter Address
277 South Cassingham Road
Columbus, Ohio 43209
Telephone: (614) 236-5698
Fax: (614) 235-CAMP
E-Mail:
Camp Pinecliffe
General Information
Date:
Name:
Street Address:
Street Address:
City:
State:
Zip Code:
Date of Birth (Optional):
Home Phone:
E-Mail Address:
Social Security Number:
Best Time To Call:
School Information
School Name:
School Address:
School Address:
School City:
School State:
School Zip Code:
School Phone:
Education
Years:
School Name
Major Subjects
Degrees Granted
Previous Employment
Dates:
Employer:
Address/Phone
Duties
Supervisor
Reason for Leaving
References
Name:
Mailing Address:
Telephone Number:
Reference Email Address:
Camp Experience
Dates:
Camp:
Camp Address:
Director:
Camper/Staff:
Personal Information
Do you posses a valid driver's license?
Yes
No
Issuing State:
License Number:
Have you ever been convicted of any crime,
including child abuse or sex abuse crimes?
Yes
No
If yes, please explain:
If hired, would you desire housing for any person(s)
other than yourself at camp?
Yes
No
Salary desired:
For what position(s) are you applying?:
Keep in mind we provide room, board,
travel monies, and laundry.
Dates Available (from/to):
Do you have any physical impairments or restrictions?:
Activity Rating
Please put the number "1" before those activities listed below that you can teach and organize as an expert; "2" for those activities in which you can assist in teaching; and "3" for those activities which are just your hobby; "C" for those activities in which you have current certification.
Crafts:
Basketry
1
2
3
C
Ceramics
1
2
3
C
Jewelry
1
2
3
C
Leather
1
2
3
C
Macrame
1
2
3
C
Painting
1
2
3
C
Sketching
1
2
3
C
Silver
1
2
3
C
Stained Glass
1
2
3
C
Weaving
1
2
3
C
Dance
Folk
1
2
3
C
Jazz
1
2
3
C
Modern
1
2
3
C
Social
1
2
3
C
Square
1
2
3
C
Drama/Music
Lead Singing
1
2
3
C
Music Director
1
2
3
C
Theater Director
1
2
3
C
Transpose/Sight Read
1
2
3
C
Gymnastics
Balance Beam
1
2
3
C
Cheerleading
1
2
3
C
Floor Exercise
1
2
3
C
Uneven parallel bars
1
2
3
C
Horseback Riding
Barn Work
1
2
3
C
Hunt Seat
1
2
3
C
Jumping
1
2
3
C
Riding Instruction
1
2
3
C
Trail Riding
1
2
3
C
Landsports
Archery
1
2
3
C
Basketball
1
2
3
C
Field Hockey
1
2
3
C
Golf
1
2
3
C
Judo/Karate
1
2
3
C
Lacrosse
1
2
3
C
Soccer
1
2
3
C
Softball
1
2
3
C
Tennis
1
2
3
C
Track and Field
1
2
3
C
Volleyball
1
2
3
C
Low Ropes
Low Elements
1
2
3
C
Ropes Course
1
2
3
C
Nursing
Aide
1
2
3
C
Licensed Practical
1
2
3
C
Registered
1
2
3
C
Miscellaneous
Camp Fire Programs
1
2
3
C
Evening Programs
1
2
3
C
First Aid/CPR
1
2
3
C
Secretary
1
2
3
C
Story Telling
1
2
3
C
Worship Services
1
2
3
C
Outdoor Living
Campcraft Instruction
1
2
3
C
Mountain Climbing
1
2
3
C
Nature
1
2
3
C
Overnight Trips
1
2
3
C
Tripping and Hiking
1
2
3
C
Photography
Camera Operation
1
2
3
C
Dark Room
1
2
3
C
Video
1
2
3
C
Smallcraft
Canoeing
1
2
3
C
Rowing
1
2
3
C
Sailing
1
2
3
C
Swimming
Diving
1
2
3
C
Lifeguarding
1
2
3
C
Synchronized
1
2
3
C
Waterski
Ski Boat Driving
1
2
3
C
Trick Skiing
1
2
3
C
Water Skiing
1
2
3
C
Please list additional expertise or certifications (not previously listed):
What contributions do you think you can make at camp?
What contribution do you think a well run camp can make to its campers?
Please write a brief biographical sketch, including specialized training in camping, and experience or training in other fields which might have a bearing on the position(s) for which you are applying:
The statements in this application are true, complete and correct. I understand that any misrepresentation or omission of information shall be considered suffcient reason for withdrawal of an offer or subsequant termination of employment. I hereby authorize Camp Pinecliffe to conduct a personal felony record search. All statements become part of any future employee personnel files. I understand that, if employed, I will be an at-will employee and that any agreement to the contrary must be in writing and signed by the Director of Camp Pinecliffe.