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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
