EFNC Camp Counselor Application 2020

Applicant Information

First Name

Last Name

Gender

MaleFemale

Phone

Age

Date of Birth

Email

Address Line 1

Address Line 2

City

State

Postal Code

Qualifications

What are your qualifications and experience?

Employment experience:

What are your special skills?

Are you CPR Certified or have any other certifications? If yes, please explain and give expiration dates.

YesNo

Please describe your CPR certification:

Expiration Date of your CPR Certification

Are you fluent in any languages other than English?

YesNo

List Languages

Employment and Volunteering Experience

Current Employment Status

EmployedUnemployed

Current Job Position:

Employer:

Years

Contact Person

Email / Phone

Previous Job Position

Employer

Years

Contact Person

Email / Phone

Please list any previous volunteer experience.

Recent:

Years

Activity:

Contact Person:

Email / Phone

Please attach your resume to this application:

References: Please list 3 references. At least 1 should be a professional reference.

Length of time known

Name:

Relationship

Contact Information Phone/Email

Background Check:

In order to work with children/teens, a background check must be completed. Applicants do have the right to refuse that a background check be conducted, although refusing consent to a background check will affect our decision. Please fill in the blanks below and sign in the space provided to complete your application. All information will be kept confidential, and only those with privilege will review applicant information.

Full Legal Name

Date of Birth

Driver's License#

State Issued

Current Address

Previous Address

Has the applicant ever been charged or convicted of a crime (especially sex related)?

YesNo

Please provide details of charges or convictions:

This is to confirm that my printed or typewritten name below is the same as my signature and indicates that the information above is accurate.

E-Signature

Date

In case of emergency, please notify:

Name

Contact Information Tel No./Email

Relationship

Release of information: Indicate information that may be posted on the www.epilepsynorcal.org website. Your listing below confirms that we may list this on our website.

Name: First and/or Last

City you live in

Photo: Please upload a recent Photo

Upon accepting your application, those working with children must undergo a background check, regardless of previous volunteer experience. Background check must take place at least 2 weeks prior to the first scheduled volunteer event.

This is to confirm that my signature or name below indicates that the information above is accurate and have agreed to the above statement.

E-Signature:

Date:

Confidentiality Agreement:

In the course of your work as an EFNC volunteer, you will come into

contact with confidential information. By submitting this form you acknowledge and

agree that at all times the information will remain confidential.

You further agree that during the term of your relationship you will only

use the material provided by the EFNC for the benefit of your role as a volunteer.

In the event that you leave your role as volunteerr you will not replicate

or provide it to any third parties.

Thank you for applying to volunteer with us!