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FERRUM COLLEGE SUMMER ENRICHMENT CAMP COUNSELOR-IN-WAITING APPLICATION NAME: SOCIAL SECURITY NUMBER:__________________________ CURRENT ADDRESS: DATE OF BIRTH: AGE:____________ CURRENT TELEPHONE: _____________________________ GRADE LEVEL IN SCHOOL:____________________________ EMAIL ADDRESS:________________________________________ NAME OF SCHOOL: CITY OR COUNTY:____________________________________ CLASSES YOU ARE TAKING THIS YEAR AND GRADES ON LAST REPORT CARD: . . HAVE YOU ATTENDED FCSEC AS A CAMPER? IF YES, WHAT YEAR(S):___________________________________ OTHER CAMP EXPERIENCE: (As staff or camper) NAME OF CAMP ADDRESS DATES OF ATTENDANCE NATURE OF ATTENDANCE EMPLOYMENT/VOLUNTEER EXPERIENCE: SUPERVISOR NATURE OF WORK DATES OF WORK TELEPHONE OTHER EXPERIENCE: List membership in clubs and organizations, special training, and leadership experiences: __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ Camp T-Shirt Size---Adult Small ____ Medium ____ Large ____ Extra Large ____ XXLarge ____ ATTACH A TWO-PAGE ESSAY TELLING ABOUT YOURSELF AND WHY YOU WOULD MAKE A GOOD C-I-W AT FCSEC. C-I-W applicants must provide references from the following. Provide names and telephone numbers of people from whom you will be requesting references. Name of Reference Telephone Number Principal or Guidance Counselor Teacher Adult Friend Adult Friend Continuation on Back As part of your duties as a C-I-W at FCSEC, you may be asked to assist with classes and workshops. To give us an idea of your interests and talents, please check areas below that you could assist with. Space is provided to describe your special skills and experiences, where relevant. AREA OF INTEREST DESCRIBE SPECIAL INTERESTS, EXPERIENCES, ETC. Crafts Sports Dance Musical Instruments Drawing Drama Photography Foreign Language Camp Songs Other Other PLEASE SIGN BELOW AND RETURN THIS FORM NO LATER THAN APRIL 15, 2008. I CERTIFY THE INFORMATION GIVEN ON THIS APPLICATION IS CORRECT TO THE BEST OF MY KNOWLEDGE. SIGNATURE _____________________________________________________ DATE ____________________________________ MAIL TO: FCSEC COUNSELOR-IN-WAITING PROGRAM C/O CHIP PHILLIPS, DIRECTOR OF SUMMER PROGRAMS P. O. BOX 1000, FERRUM COLLEGE, FERRUM, VA 24088-9001 Ferrum College does not discriminate on the basis of race, religion, color, national origin, age, veteran status, gender or disability in admission to, access to, treatment in or employment in its programs or activities. The following person has been designated to handle inquiries regarding the nondiscrimination policies: Coordinator of Human Resources, John Wesley Hall 204, Ferrum College, Ferrum, VA 24088-9001, (540) 365-4235. Inquiries concerning the application of nondiscrimination policies may also be referred to: Regional Director, Office of Civil Rights, US Department of Education, 3535 Market Street, Room 6300, Philadelphia, PA., 19104-3326.
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