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					                                                                                                               620 Scugog Line 4

                                                                 Summer 2012                                     Port Perry, Ont.,
                                                                                                                          L9L 1B5

                                                                Job Application                                     416-526-4671
                                                                                                                   905-985-6527
                                                                  Email: lisagraves@crossleyaquatics.com
                                                                  Website: www.crossleyaquatics.com




                                                   FAMILY INFORMATION
Surname:                                                         Home Phone:
Street:                                                          Postal Code:
City:                                                            Country:
Mother's Name:                                                   Bus. Ph:
Father's Name:                                                   Bus. Ph:
                                                 EMPLOYEE INFORMATION
Employees Surname:                                               Cell Phone:
Employees First Name:                                            Email:
Birth date (d/m/y):                                              Social Insurance Number:
Health Card Number:                                              Days Available (circle):      Thursday            Sunday




Qualifications: Please document all relevant qualifications & supply copies!
Qualifications                             Date Issued                    Expiry Date                   Location Received

Water Safety Instructor

Life Saving Instructor

Standard First Aid

National Lifesaving Society

High Five

Police Check (mandatory)




Acknowledgement and Authorization:
    Check                                                          Review


                     I certify that all answers given herein are true and complete to the best of my knowledge.


                     I have read and will abide by Crossley Aquatics employment contract.


Signature of Applicant: ______________________________________________                      Date: _____________________________
 Crossley Aquatics Wilderness Swim Camp 2012 Health and Medical Form
Camper’s Name_______________________ Health Card #_______________________
Family Doctor ________________________ Telephone (Doctor)___________________

Please circle any of the following health or medical conditions:

Please indicate any significant medical conditions, physical limitations, or any other concerns that might
affect your child’s full participation in camp activities
  Diabetes                                 Chronic Nosebleed             Digestive upsets            Hemophilia
  Ear, Nose, Throat infections              Fainting Spells                       Feet or Leg problems      Hernia
  Heart problems                           Rash                          History of Head injuries
  Migraine                                 Asthma                        Recent illness or operation
  Urinary infections                       Rheumatic Fever                 Seizures
  Other _________________________________________
Give details of usual treatment for each of the above conditions indicated
_____________________________________________________________________________
_____________________________________________________________________________
Please explain if your child has any medical condition that requires modification of his/her program
______________________________________________________________________________________
____________________________________________________________________
Allergies/Asthma
Please list all known confirmed allergies and/or asthmatic triggers:
           Allergy / Asthma                      Rate Severity                        Reaction/ Treatment
                                             Mild --------- Life Threatening
          _______________________ 1                   2        3     4 ___________________________
          _______________________ 1                   2        3     4 ___________________________
Does your child have an EpiPen?                                                           Yes     No
Does child have an asthma inhaler?                                              Yes     No
             If allergy or asthma is Life-Threatening, a Doctor’s Signature is required below.
            Campers must bring required medications for the duration of their stay at camp.
Medication
All medication shall be collected and monitored by the camp director
Does your child take prescribed medication on a regular basis?                            Yes     No
Name of Medication            Reason            Dosage                  Method of Administration
_________________           _____________ ____________                 _____________________
_________________           _____________ ____________                 _____________________

Is the camper self medicating?                                                        Yes  No
May camp staff administer sun screen, bug repellent (10% deet), and/or afterbite to your child?
                                                                                      Yes  No
If the answer above is No, please specify alternative ____________________________
Dietary
Please list any foods your child should not eat for medical, dietary, or religious reasons
______________________________________________________________________
General
(1) Does your child wear or carry medical alert identification?              Yes      No
If Yes, please specify what is written upon it ___________________________________
(2) Does your child have any special fears or conditions, the knowledge of which will allow the camp director
to make the camper’s excursion more relaxed:                      Yes        No
If yes, please explain ____________________________________________________

Consent of Parent/Guardian
Should it become necessary for my son/daughter to have medical care, I hereby give camp staff permission
to use their best judgment in obtaining the best of such service for my child. I also understand that in the
event of such illness or accident, I will be notified as soon as possible.
Name of Parent/Guardian (please print) _______________________________________
Signature of Parent/Guardian___________________________ Date ____________________________
Doctor’s Signature ___________________________________ Date ____________________________
                    Only required for campers with life threatening medical or dietary conditions
                                                                                           Lisa Graves
                                                                                   620 Scugog Line 4
                                                                             Port Perry, Ont., L9L 1B5
                                                                                        416-526-4671
                                                                                       905-985-6527
                                                                email: lisagraves@crossleyaquatics.com
                                                                  website: www.crossleyaquatics.com



                                Employment Contract

Please find below the basic expectations of a staff member. Mostly, I just want to have a
great time! This will happen if you follow these simple guidelines:

            o   Arrive at camp in time for morning meeting for daily preparations
            o   Work a fair block of extended hours each week
            o   Help to set up and clean up
            o   ALWAYS PROVIDE A SAFE AND ENJOYABLE ENVIRONMENT FOR
                ALL CAMPERS
            o   Miss work only due to extreme illness
            o   Uniform: Wear Camp t-shirt daily, whistle, swim suits, clothing for all weather
                conditions
            o   Prepare Swim lessons as required
                     Lesson Plans daily
                     Track all swimmers on worksheets to be completed & submitted
                              Track the student success weekly ‘l’ means introduced, + means
                                pretty good and + means skill meets expectations
                             When a student passes ‘C’
                    Complete accurate and professional report cards weekly
            o   During swim class
                    Limit deck time to 5 minutes
                    Engage in the student swimming, follow them as they swim so that you
                       look at what they need.
                    Give positive feedback and constructive feedback every time
                    Look like you really care about their success
                    Communicate with Senior Instructor or Director if you are having
                       difficulty
                    Never leave a preschool students or Swim Kids 1 & 2 at the wall
                       unattended. Have 1 on your back and 1 on your front or leave an
                       assistant at the wall.
                    Always have the students practicing


I have read the above and will do my best to follow the expectations. I understand that I will start
at a weekly salary of $______/week, minus government deductions.



__________________________ _________              ________________________
Signature                         Date                   Printed Name

				
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