Please return by May 13, 2011 to:
       Extension Office, 4-H Youth Development Agent, P.O. Box 460, Antigo, WI 54409

*As a Camp Counselor this year, you will be expected to attend 6 hours of Camp Counselor
Training. The dates for these trainings are May 26, 2011 – 5:30 – 8:30 p.m. at the Langlade
County Resource Center and June 13, 2011 – 5:30 – 8:30 p.m. at 4-H Camp Susan.

Name ______________________________Club_______________________________________

Address                                    City_______________________________

Grade as of January 1, 2011             Date of Birth____________

1.     Why do you want to be a camp counselor?

2.     Have you ever been a camp counselor? Yes          No______

       Please list where and when?

       Please list duties and responsibilities:

3.     What qualifications do you think a camp counselor should have?

4.     Describe experiences you've had that would help you be a good counselor:

5.     Have you had swimming instruction? Yes          No_____

       What level reached?
       Date and organization examined?
       Have you had First Aid or CPR? Yes          No_____

       Date certified and organization?
6.       Camps you are interested in being a counselor for?

July 7, 2011 Community Camp                       July 11 – 13, 2011         younger             July 13 – 15, 2011

July 6, 2011 Day Camp____

        Counselors for Day Camp and the Community Camp should be 8th grade and up.
        Counselors for Younger Camp should be 9th grade and up.
        Counselors for Older Camp should be 10th grade and up.

7. Check activities you have experience in and are interested in:

____Canoeing                         ____Crafts                  ____Swimming                         ____Fishing

____Hiking                           ____Nature                  ____Recreational                               Games

____Song Leading                     ____Jogging                 ____Flag Pledges

____Other: Please List______________________________________________________

                   *        The Community Camp is open to youth in 3rd – 6th grades, 4-H and non
                   4-H. It is a SEPARATE Camp and will not affect your chances of being a
                   counselor at our regular 4-H camp.
Counselor Camp Susan T- Shirt Orders
Please fill out the order below if you would like a 4-H camp counselor T -shirt. Ordered shirt will be available at
camp registration or at camp counselor training. No extra shirts will be ordered. Money must be turned in with this
order and application. Sizes are adult: S, M, L, XL.

             Name                                          Camp Attending                     Size

*Note: The design and cost of the t-shirt is yet to be determined. They
are generally about $8 and are related to the camp theme in some way.

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