Midtown Center for boys Summer Camp Counselor Application
This application is for Midtown Summer Camp Counselors only. If you want to apply to be a Summer advisor, please contact the Center Director, Pedro Caranti, directly by calling Midtown at 773-292-2662.
Choose one:
Please select...
Female
Male
Error
Sorry, but you are filling out the wrong application. Please email Molly Powers at the
Metro Achievement Center for girls
at mpowers
@midtown-metro.org
for more information.
Page 2
Check below which position you are applying for
:
Midtown Summer Camp Counselor
Personal Info
Contact Information
First Name
Middle
Last Name
Date of Birth
Email
Phone at College
Cell Phone
Preferred Contact Method
Please select...
Phone at College
Home Phone
Cell Phone
Email
Current Address at College
Campus Address Line 1
Campus City
Campus State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Campus Zip Code
Referred By
Did you ever attend Midtown?
Please select...
Yes
No
Summer Dates You Are Available
Midtown Program Info
There is a dress code -- a Midtown Polo shirt. Select your shirt size.
Please select...
S
M
L
XL
XXL
Home Info
Home Phone
Address
City
State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
Emergency Contact
Emergency Contact First Name
Emergency Contact Last Name
Emergency Contact Relationship
Emergency Contact Phone
Applicant Information
Student Race/Ethnicity
Multi-racial
African American or Black
Asian or Pacific Islander
Latino or Hispanic
Native American
White
Academic Level for next Fall (NOT CURRENT GRADE)
High School Senior
College Undergraduate
College Graduate
Name of School Planning to Attend next Fall
If possible, please upload a copy of your most recent report card.
Preferred Role
Please select...
Coach
Sports Instructor
Support Staff
What is your major weakness in the workplace? How will you handle criticism from your managers?
Are there any dates that you will not be able to attend the program? Failure to notify Midtown about missed dates will jeopardize your participation in the future.
Applicant Parent/Guardian Information
Primary Contact Relationship
Please select...
Mother
Father
Guardian
Other
Primary Contact's First Name
Primary Contact's Last Name
Primary Contact's Phone Number
Primary Contact's Email
Primary Language Spoken at Home
Please select...
Spanish
English
Other
Secondary Contact Relationship
Please select...
Mother
Father
Guardian
Other
Secondary Contact's First Name
Secondary Contact's Last Name
Secondary Contact's Phone Number
Secondary Contact's Email
Applicant Medical Information
Name of Health Insurance Carrier
Please select...
Aetna
Assurant Health
Blue Cross Blue Shield of Illinois
Coventry Health Care of Illinois, Inc.
Coventy Health Care of Missouri, Inc.
Humana
Land of Lincoln Health
My Health Alliance
United Healthcare Life Ins. Co.
United Healthcare of the Midwest, Inc.
Other
If you marked OTHER, please list the name of your health insurance carrier here:
Group Policy Number
Doctor's First Name
Doctor's Last Name
Doctor's Phone Number
Doctor's Street Address
D
octor's City
Doctor's State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Doctor's Zip Code
Does the student have any allergies, chronic illnesses, or medical conditions? If yes, please describe. If not applicable, write NA.
Is the student prescribed an inhaler or any other special medications? If yes, please explain any instructions. If not applicable, write NA.
Applicant Informed Consent and Acknowledgement
I certify that I have read the Medical Release and Parent
Authorization waiver and agree to the
terms and conditions
and
policy guidelines for parents and students
of the Midtown and Metro programs and am indicating my consent by checking the boxes below.
Read each section of the Terms and Conditions and then check EACH box below:
A
UTHORIZATION FOR ACADEMIC REPORTS
MEDICAL RELEASE WAIVER
PARENT RESPONSIBILITY POLICY - 1) Mandatory attendance to one parent event 2) For students in 7th-12th grades, permission to dismiss child allowing him/her to take public transportation home without a guardian present
POLICY GUIDELINES FOR PARENTS AND STUDENTS
By your clicking this box as your email signature, you are acknowledging that you have read, agreed to and accepted all the terms and conditions regarding your child’s attendance and participation in the programs at the Metro Achievement Center and/or Midtown Center.
Contact Information