Jan by chenmeixiu

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									Dear:

The Family Relief Summer Application Package is attached to this letter. Please sign and complete all
forms thoroughly before handing them in to avoid any unnecessary delay. All of the following are
necessary to secure an interview and to be eligible for hire. Deadline for all applications is May 14, 2010.
We will be holding interviews the week of May 30, 2010

       Summer Application Form (2 pages)
       Summer Applicant Questionnaire (2 pages)
       Oath of Confidentiality Form
       Terms of Agreement Form
       Photograph Consent Form
       Driver Information Form (if applicable)
               Photocopy of drivers license (if applicable)
               Photocopy of insurance card (if applicable)
       Direct Deposit Form
               Void Cheque or Bank Verification
       Criminal Record Check (applicant=s responsibility if hired)

The Family Relief Summer Staff Guidebook is also enclosed. The Guidebook contains policies and
procedures that must be followed by all Summer Staff, so read it carefully and sign the Terms of
Agreement Form included in your application.

The Criminal Record Check is a mandatory requirement by the Ministry of Community and Social
Services for all employees working with special needs individuals. If you have had one done within the
last 12 months and can produce a copy, as well as a copy of your driver=s license or birth certificate, this
meets Ministry guidelines and will be accepted. Otherwise you can request an original from a local Police
Force or the O.P.P. Fees may vary among Police Forces.

Applications must be completely filled out and the above requirements must accompany the
application in order to receive an interview.

When you have completed the Application Package and obtained your Criminal Record Check please mail
or drop off at the above address: Attention: Jan Paul-Barr, Worker Resource Casworker. If you have
any questions or concerns regarding Summer Employment please do not hesitate to call me at 257-7619 or
1-866-257-7618 ext. 335.

Sincerely,


Jan Paul-Barr
Lanark County Family Relief Program
                                     LANARK COMMUNITY PROGRAMS
                                                     Satelite Office:
                                   30 Bennett St. Unit 1 , Carleton Place, ON K7C 4J9
                                              257-7619 or 1-866-257-7618
                                                     Fax: 257-2209


                                SUMMER APPLICATION FORM

 New Summer Application                                                                 Updating Previous Summer File
 PERSONAL INFORMATION

 Last Name:                          First Name:                                               SIN:
 Home #:                             Address:
 Work #:
 Cell #:
 Fax #:
 E-mail:



Date of Birth: _________________________________________                               Male           Female


 EDUCATION

 Name of School/Program/or Training Course             Degree/Diploma/or Certificate                  Date of Completion




 EMPLOYMENT

 Name of Last Employer          Position                             Period of Employment             Reason for Leaving




Did you work for us last summer?             Yes               No                Which camp?___________________


Position being applied for:  Camp Director            Camp Assistant Director             Camp Counsellor
Availability:    Full-time    Part-time    A.M.  P.M.
Please tell us about your interests. Where do you think you would be the greatest asset (day camp or
youth camp)? Do you have a geographical preference?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

Describe any work related skills, experience, or training that relate to the position being applied for.
Please explain what your comfort level is with individuals with special needs? How do you feel you can
increase this comfort level over the summer?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

What do you hope to gain out of an experience with Lanark Community Programs this summer?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

Do you have a valid driver=s licence?                                                 Do you have your own transportation?


You have training in:               CPR (valid 2 yrs) expiry date__________              CPI (valid 1 yr) expiry date_________


You are willing to drive to:  Perth             Smiths Falls    Lanark Maberly                 McDonald=s Corners
                                    Carleton Place         Almonte      Pakenham                Arnprior    Other

We require two Awork related@ references whom we may contact (do not include relatives):
 Name:                                                               Name:
 Phone:                                                              Phone:
 Address:                                                            Address:




Have you attached additional sheets? Resume? Certificates? YES □ NO □
                                              LANARK COMMUNITY PROGRAMS

I hereby declare that the forgoing information is true and complete to the best of my knowledge. I understand that a false statement may
disqualify me from employment or cause my dismissal.

Signature:_____________________________                                          Date:_______________________________
                                                               Satelite Office:
                                           30 Bennett St. Unit 1, Carleton Place, ON K7C-4J9
                                                       257-7619 or 1-866-257-7618
                                                               Fax: 257-2209


                                  SUMMER APPLICANT QUESTIONNAIRE


Please answer the following questions to the best of your knowledge and ability. Picture these situations taking
place during the camp session.

1.      While at camp you over hear a counsellor ridicule a child. You approached your co-worker and voiced
        your concern. He/she felt they handled the situation appropriately. What would you do? How do you
        hope to resolve this?
        _____________________________________________________________________________________
        _____________________________________________________________________________________
        _____________________________________________________________________________________
        _____________________________________________________________________________________

2.      While walking to the park two campers are acting in a disruptive manner. How do you gain control of
        this situation while maintaining the rest of your group?
        _____________________________________________________________________________________
        _____________________________________________________________________________________
        _____________________________________________________________________________________
        _____________________________________________________________________________________

3.      You are at the playground playing on the climbers with the campers. A child falls off the top of the
        monkey bars. The child is lying on his back, crying. You are the staff in charge. What would you do?
        _____________________________________________________________________________________
        _____________________________________________________________________________________
        _____________________________________________________________________________________
        _____________________________________________________________________________________

4.      Pat is homesick. Pat is refusing to participate in any activity and keeps insisting that his parents should be
        called for a ride home. How would you handle this situation?
        _____________________________________________________________________________________
        _____________________________________________________________________________________
        _____________________________________________________________________________________
        _____________________________________________________________________________________



I hereby declare that the forgoing information is true and complete to the best of my knowledge. I understand that a false statement may
disqualify me from employment or cause my dismissal.

Signature:_____________________________                                           Date:_______________________________
5.      This is Taylor=s first experience at day camp. Taylor is very shy and does not know anyone at camp.
        What strategies would you use to help Taylor feel welcome?
        _____________________________________________________________________________________
        _____________________________________________________________________________________
        _____________________________________________________________________________________
        _____________________________________________________________________________________

6.      While colouring one morning Bailey discloses that he/she is being sexually abused at home by Dad. Keep
        in mind the policy in your guidebook.

a)      What would you do at that moment? What would you do next?
        _____________________________________________________________________________________
        _____________________________________________________________________________________
        _____________________________________________________________________________________
        _____________________________________________________________________________________

b)      Prioritize in numerical order the people to whom you would speak to about this incident.

        Bailey=s mom                   _____
        Another camp counsellor        _____
        Bailey=s dad                   _____
        CAS representative             _____
        Camp director                  _____
        Bailey=s sister (also at camp) _____
        Another relative of Bailey=s _____




I hereby declare that the forgoing information is true and complete to the best of my knowledge. I understand that a false statement may
disqualify me from employment or cause my dismissal.

Signature:_____________________________                                          Date:_______________________________
                                              LANARK COMMUNITY PROGRAMS
                                                              Satelite Office
                                             30 Bennett St. Unit 1 Carleton Place, ON K7C 4J9
                                                       257-7619 or 1-866-257-7618
                                                              Fax: 257-2209


                                OATH OF CONFIDENTIALITY FORM

                 I understand that any information related to any client
                 and/or client families, obtained through Lanark Community
                 Programs, or while acting in the capacity of Family Relief
                 Worker, is to be strictly confidential. Any breach of this
                 confidentiality could result in the immediate termination of
                 my placement. (Please be advised, however, that your legal
                 obligation to report suspected child abuse or neglect, does
                 not constitute a breach of your Oath of Confidentiality).


                                      ______________________________
                                         Worker Name (Please Print)


                                      ______________________________
                                             Worker Signature


                                      ______________________________
                                         Witness Name (Please Print)


                                    ________________________________
                                            Witness Signature

                                      ______________________________
                                                   Date

I hereby declare that the forgoing information is true and complete to the best of my knowledge. I understand that a false statement may
disqualify me from employment or cause my dismissal.

Signature:_____________________________                                           Date:_______________________________
I hereby declare that the forgoing information is true and complete to the best of my knowledge. I understand that a false statement may
disqualify me from employment or cause my dismissal.

Signature:_____________________________                                          Date:_______________________________
                                              LANARK COMMUNITY PROGRAMS
                                                              Satelite Office
                                             30 Bennett St Unit 1 Carleton Place, ON K7C 4J9
                                                      257-7619 or 1-866-257-7618
                                                              Fax: 257-2209


                                     TERMS OF AGREEMENT FORM

                 I have read and understand the policies and procedures as
                 set out in the Family Relief Worker=s Guidebook - The
                 Information Guide for Family Relief Workers. I understand
                 as a Purchase of Service Worker, I am not covered by WSIB,
                 CPP or Liability Insurance. I am responsible to claim my
                 income and will receive a T4a slip from the Finance Dept. I
                 agree to abide by and enforce the policies and procedures to
                 the best of my ability at all times. I am aware that a
                 voluntary violation of any of these policies could result in the
                 termination of my employment at Lanark Community
                 Program=s Family Relief Program.

                                      ______________________________
                                         Worker Name (Please Print)

                                      ______________________________
                                             Worker Signature

                                      ______________________________
                                         Witness Name (Please Print)

                                      ______________________________
                                             Witness Signature

                                      ______________________________
                                                   Date


I hereby declare that the forgoing information is true and complete to the best of my knowledge. I understand that a false statement may
disqualify me from employment or cause my dismissal.

Signature:_____________________________                                          Date:_______________________________
                                              LANARK COMMUNITY PROGRAMS
                                                        Satellite Office Location:
                                                30 Bennet St Carleton Place, ON K7C 4J9
                                                      257-7619 or 1-866-257-7618
                                                             Fax: 257-2209

                              APPLICANT PHOTOGRAPH CONSENT FORM


                 I grant permission to The Lanark County Family Relief
                 Program and it=s staff to take my picture during applicant
                 interviews. I understand that this photograph will be used
                 for the purpose of reference and hiring within the Worker
                 Recruitment and Placement Department of the Family Relief
                 Program.


                                      ______________________________
                                         Worker Name (Please Print)


                                      ______________________________
                                             Worker Signature


                                      ______________________________
                                         Witness Name (Please Print)


                                      ______________________________
                                             Witness Signature


                                      ______________________________
                                                   Date


I hereby declare that the forgoing information is true and complete to the best of my knowledge. I understand that a false statement may
disqualify me from employment or cause my dismissal.

Signature:_____________________________                                          Date:_______________________________
                                                   LANARK COMMUNITY PROGRAMS
                                                              Satellite Office Location:
                                                  30 Bennett St. Unit 1 Carleton Place, ON K7C 4J9
                                                            257-7619 or 1-866-257-7618
                                                                   Fax: 257-2209

                     FAMILY RELIEF WORKER DRIVER INFORMATION FORM

WORKER=S FULL NAME:

Do you have a valid Driver=s Licence?                                                                                             YES  NO

Do you have your own transportation and/or vehicle?                                                                               YES  NO

If under 25 years of age, have you taken driver training?                                                                         YES  NO

Have you ever been convicted of an offence for which a pardon has NOT been granted?                                               YES  NO


                                            THIRD PARTY LIABILITY INSURANCE

Third party liability insurance is designed to provide protection to you (the insured) for bodily injury or death of
any persons or damage to their property arising out of ownership, use or operation of an automobile.

A minimum amount of Third Party Liability Insurance is mandatory by law. In Ontario this limit is $2 million
however, as outlined below, this minimum amount of insurance is not sufficient in the event of a tragedy. It is
therefore, not only wise but socially responsible to have an adequate amount of insurance even though there may
not be a legal compulsion to do so beyond certain minimum limits.

We recommend strongly the minimum Third Party Liability coverage carried by you (an insured) be $2 million
and, if you can afford more coverage, we recommend you do so.



To what limit are you insured for Third Party Liability Insurance? ____________________________________

Name of Insurance Company: _________________________________________________________________

Insurance Expiry Date:_______________________________________________________________________

                           Please attach a copy of Drivers License and Insurance

I affirm that the information provided above is correct and that no information regarding my driving record is being withheld.




I hereby declare that the forgoing information is true and complete to the best of my knowledge. I understand that a false statement may
disqualify me from employment or cause my dismissal.

Signature:_____________________________                                                   Date:_______________________________
Signature:___________________________________________________________                 Date:________________________________________




I hereby declare that the forgoing information is true and complete to the best of my knowledge. I understand that a false statement may
disqualify me from employment or cause my dismissal.

Signature:_____________________________                                          Date:_______________________________
                                              LANARK COMMUNITY PROGRAMS
                                                         Satellite Office Location:
                                             30 Bennett St. Unit 1 Carleton Place, ON K7C 4J9
                                                       257-7619 or 1-866-257-7618
                                                              Fax: 257-2209

                                  DIRECT DEPOSIT INFORMATION FORM


WORKER=S FULL NAME:                                                               BIRTH DATE:

HOME PHONE:                                                                       SIN #:

WORK PHONE:

ADDRESS:




BANKING INFORMATION REQUIRED:

Bank Name:_______________________________________________________________________________

Bank Branch: _____________________________________________________________________________

Bank Address:_____________________________________________________________________________

Bank Branch Number:______________________________________________________________________

Bank Account Number: ____________________________________________________________________

Type of Account:___________________________________________________________________________


**Please attach a void cheque to verify the above information.




I hereby authorize Lanark Community Programs to deposit my Family Relief pay in the above noted bank account.


I hereby declare that the forgoing information is true and complete to the best of my knowledge. I understand that a false statement may
disqualify me from employment or cause my dismissal.

Signature:_____________________________                                           Date:_______________________________
_______________________________________                                         ___________________________________
(Signature)                                                                     (Date Signed)




I hereby declare that the forgoing information is true and complete to the best of my knowledge. I understand that a false statement may
disqualify me from employment or cause my dismissal.

Signature:_____________________________                                          Date:_______________________________

								
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