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APPLICATION FOR SPORTS CAMPS RESIDENTIAL COUNSELOR
University of Iowa
Return this application by 5:00 PM Friday, February 19, 2010 to Josh Berka, Sports Camps Director, 203 Field
House. Each application will be screened and applicants will be notified by phone whether they have been
selected for interview.
The University of Iowa requests this information for the purpose of processing you employment application. No persons outside the University are
routinely provided this information. Responses to items marked “optional” are optional; responses to all other items are required. If you fail to provide
the required information, Summer Sports Camps may not consider your application.
Name_____________________________________________ _____________/_____________/____________
Last First Middle Social Security Number
Current Address _________________________________________ Phone ________________________
City, State, Zip __________________________________________ Sex _______Male _________ Female
Permanent Address _______________________________________ Phone ________________________
City, State, Zip ___________________________________________ Email Address__________________
Class standing as of Fall 2010: ____Sophomore ____ Junior ____Senior ____Graduate ____Other - ___________________
Major
Do you have a valid driver’s license? _____YES _____ NO
Have you received a moving violation in the last 2 years? ____YES ____NO
Would you feel comfortable driving a 15-passenger maxi-van? ____YES ____NO
Have you ever been convicted of a felony? _____ YES _____ NO ______ If YES, explain the nature of this
conviction. _______________________________________________________________________________
_________________________________________________________________________________________
Have you been convicted of a crime against a child? _____ YES _____ NO If YES, explain the nature of this
conviction. _______________________________________________________________________________
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Have you applied previously? _______ YES ______ NO If YES, When ______________________
Have you been employed as a University of Iowa Sports Camp Counselor previously?
______ YES ______ NO If YES, When ______________________
If you have previously been employed as a Sports Camps Counselor, why are you interested in working with
Sports Camps again and what were your most outstanding experiences as a Counselor?
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SC Counselor Application - Page 2
Where did you hear about Sports Camps Counselor Positions? _____ FRIEND, _____ FLYER, _____ COACH
_____ ADVISOR, _______ CLASS, _______ OTHER? _____________________________________________
Would you have any commitments that would take you away from camp? _____ YES ______ NO
If yes, please explain _____________________________________________________________________________________
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Please list any camps you have worked or attended
CAMP NAME TYPE OF CAMP DATES ATTENDED OR WORKED?
_________________________________________________________________________________________________________
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Other Work Experience (please include any paid or volunteer experience you have had working with children and/or
adolescents)
NAME OF EMPLOYER ADDRESS OF EMPLOYER TYPE OF WORK DATES EMPLOYED
_________________________________________________________________________________________________________
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What do you feel is the most important quality needed to work with children and/or adolescents? List examples
from your own work experiences.
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SC Counselor Application - Page 3
Discuss why you would be an effective Sports Camps Counselor.
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Please return TWO completed reference forms, which are attached to this application. Include one
from your current or most recent supervisor. DO NOT use friends, relatives, or family members as
references.
THIS IS TO CERTIFY THAT THE INFORMATION IN THIS APPLICATION IS ACCURATE.
SIGNATURE___________________________________ DATE_____________________________
The University of Iowa does not discriminate in its educational programs and activities on the basis of race, national origin, color, and creed. religion, sex, age,
disability, veteran status, sexual orientation, gender identity, or associational preference. The University also affirms its commitment to providing equal
opportunities and equal access to University facilities. For additional information on nondiscrimination policies, contact the Coordinator of Title IX, Section 504,
and the ADA in the Office of Affirmative Action, (319) 335-0705 (voice) or (313) 335-0697 (text), 202 Jessup Hall, The University of Iowa, Iowa City, Iowa, 52242-
1316.
Individuals with disabilities are encouraged to attend all University of Iowa sponsored events. If you are a person with a disability who requires and
accommodation in order to participate in this program, please contact Josh Berka at (319) 335-9297. 01/10
