Personal Information
I am over 18 Years Old
Name		Gender	Male Female
Social Security #
Date of Birth	January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 4 digit year
Current Year in School		Driver's License #
Home Address
Street
City		State	AL AK AZ AR CA CO CT DE 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 DC WV WI WY
Zip		Country
Phone		E-mail
Secondary or School Address
Name of School
Street
City		State	AL AK AZ AR CA CO CT DE 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 DC WV WI WY
Zip		Country
Phone		E-mail
How often do you check your E-mail?		Never Less than once a week Once a week Two to three times a week Once a day More than once a day
If in College, Major		Career Goal
Emergency Contact
Name
Relationship to Applicant
Phone (day)		Phone (evening)
Cell
Education, Training and Experience
School One
Name
Address
Days Attended		to
Did you graduate?	Yes No	Degree or Diploma
School Two
Name
Address
Days Attended		to
Did you graduate?	Yes No	Degree or Diploma
School Three
Name
Address
Days Attended		to
Did you graduate?	Yes No	Degree or Diploma
Do you speak, write, or understand any foreign languages?		Yes No	If yes, which language?
Age Preference (rank 1 through 3: 1 = highest, 3 = lowest)		Ages 7-9 1 2 3 Ages 10-12 1 2 3 Ages 13-15 1 2 3
How did you hear about us?
Employment History
Employer One
Company Name		Supervisor's Name
Employment Dates		To
Phone
Describe Work
Reason for Leaving
Employer Two
Company Name		Supervisor's Name
Employment Dates		To
Phone
Describe Work
Reason for Leaving
Last camp employment or attendance
Camp Name		Camp Director
Years at Camp		Street
City		State	AL AK AZ AR CA CO CT DE 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 DC WV WI WY
Zip		Phone
Please Check	Counselor Camper Support Staff
References
List three references below. References should be from an employer, supervisor, teacher or coach - we will not accept references from co-workers, family members, or friends. Please send reference letters and camp-addressed envelope to your reference. They must mail the reference directly to us. » Click here to download a reference form for Camp White Eagle » Click here to download a reference form for Camp Kupugani
Reference One
Name		Address
Phone		Relationship
Reference Two
Name		Address
Phone		Relationship
Reference Three
Name		Address
Phone		Relationship
Health Information
Realizing that camp counseling often involves extensive physical activity, please list any special conditions, problems or limitations, including physical or mental impairments, that might interfere with your ability to perform the job for which you are applying:
Do you have any special dietary needs?			Yes No
Are you required to take any medications?			Yes No
If yes, please describe type and purpose:
Are you willing to obtain necessary certifications if you do not already have them?			Yes No
Camp Staff Profile
Please describe your race(s)/ethnicity(-ies)*:
*Providing the information above is optional, yet it would be tremendously helpful if you did.  Because we are addressing issues of difference, it is essential that we have a diverse group of cabin counselors.  We not only strive for racial/ethnic diversity, but also for diversity of gender, socio-economic class, religion, culture, physical ability, personality, etc.  This information will be used only to determine this balance.
Please describe any other ways by which you identify yourself (such as socio-economic class, religion, culture, physical ability, sexual orientation, background, etc.) that you would like to share with us:
1. How do you think children might benefit from a camp experience?
2. What do you perceive to be the responsibilities of a camp counselor?
3. Why do you want to participate in our camp? What do you hope to gain from the program?
4. How do you think you can contribute to the program?
5. Describe both leadership positions and any experience working with children, especially 7 – 15 year olds, if applicable.
6. Have you ever lived away from home for several weeks before?  When?  What do you foresee being your greatest challenge with the lifestyle at camp?  How will you manage the challenges?
7. Please share a time when you experienced or witnessed prejudice or discrimination and how you dealt with the situation.
8. Describe what the word “multiculturalism” means to you.  Please answer this question as if you are speaking to a 10 or 11 year-old.
9. Is there anything else you would like us to know about you?
Camp Activities
On the following list, please put a number “1” at the left of those activities you could organize, coach and teach proficiently.  You must be personally skilled and experienced.  Put a number “2” by those activities you could actively assist in teaching.  Put a “3” by those activities to which you have had some exposure.
ADVENTURE		ARCHERY
Low Ropes - Initiatives		Archery
Rock Climbing Wall
Zip Line
BIKING		CANOEING
Biking		Lake
		Open water
CRAFTS		DANCE
Candle Making		Aerobics / Hip Hop
Ceramics		Ballet
Enamel		Folk
Jewelry		Jazz
Leather Craft		Line
Macramé / Hemp		Modern
Paper Crafts
Sketching
Tie Dye
Weaving
Woodwork
DRAMA		FISHING
Acting		Fishing
Drama Production
Improv
Mime
Skits
Story telling
FITNESS		HIKING
Cross Training (Aerobics / Hand weights)		Mountaineering
Karate		Survival Skill
Kickboxing (Taebo)		Trail Hikes
Personal Fitness
Self Defense
Step Aerobics
Tae Kwon Do
Yoga
KITCHEN		LANDSPORTS
Cooking		Cricket
Baking		Football
Food Prep		Frisbee
Supervision / Mgmt.		Playground Games
		Soccer
		Softball
		Volleyball
		Other
LANGUAGES		MUSIC
French		Guitar
Sign		Lead Group Singing
Spanish		Piano
Other		Solo
NATURE / ECOLOGY		OFFICE
Animal Care		Bookkeeping
Astronomy		Data Entry
Geology		PC Computer Skill
Plant & Animal Identification		Secretarial
		Typing
		Web Development
RIFLERY		SWIMMING
NRA Level		Basic Water Safety
		Competitive
		Diving
		Life Saving
		Swimming
		Water Games
TEAMS		OUTDOOR LIVING
Low Ropes		Backpacking
High Ropes		Camping Skills
Climbing		GPS / Compassing
Team Building		Hiking
		Knots
		Orienteering
		Outdoor Cooking
OTHER
Auto Mechanics
Campfire Programs
Carpentry
Conservation Work
Cooking
Creative Writing
Electrical
Juggling
Landscaping
Other
Name any additional skills that you could incorporate in the program.
Current Certifications
Required First Aid / CPR		Date Received
Lifeguard Certification		Date Received
Water Safety Instructor		Date Received
EMT		Date Received
Wilderness First Responder		Date Received
Wilderness First Aid		Date Received
Riflery Instructor		Date Received
Archery Instructor		Date Received
Other
Important guidelines for Camp White Eagle / Camp Kupugani staff
As a staff member, you will be giving up a great deal of privacy and comfort, working long and demanding hours, adhering to camp policies which may be limiting (curfew, time on, time off, lack of privacy, etc.)
I understand and will adhere to the lifestyle change that camp may bring with it.			Yes No
Smoking: Smoking is not permitted on camp property at any time.
Will you adhere to this policy?			Yes No
Illegal Drugs: Possession of, being under the influence of, or being on camp property with any illicit drug like marijuana is not permitted and will result in immediate dismissal.  All staff members are expected to be ready for work with campers anytime they are on camp or at a camp function.
Will you adhere to this policy?			Yes No
Alcohol: Absolutely NO alcoholic beverages may be brought onto camp property and no one may return to camp under the influence.
Will you adhere to this policy?			Yes No
Background Information
**If you answer “YES” to any of the following three questions, please indicate the convictions, location, police or court dates and circumstances.
1. Have you ever been convicted of, or pleaded guilty to, a criminal charge of child abuse or sex related crimes?			Yes No
If Yes, please explain:
2. Are you now under allegations for any violation of the law?			Yes No
If Yes, please explain:
3. During the past ten years, have you been convicted, imprisoned, on probation or on parole (includes felonies, misdemeanors, firearms, or explosive violations and all other offenses)?			Yes No
If Yes, please explain:
Please read and initial beside each paragraph
I authorize Camp White Eagle/Camp Kupugani to investigate all statements in this application and to secure any necessary information from all my employers, references and academic institutions.  I hereby release all those employers, references, academic institutions and Camp White Eagle/Camp Kupugani from any and all liability arising from their giving or receiving information about my employment history, my academic credentials or qualifications and my suitability for employment at Camp White Eagle/Camp Kupugani.
I further understand that any false or misleading statements will be sufficient cause for rejection of my application if Camp White Eagle/Camp Kupugani has not employed me and for immediate dismissal, if Camp White Eagle/Camp Kupugani has employed me.
I hereby authorize Camp White Eagle/Camp Kupugani or authorized representatives of the company bearing this release to obtain and release any information pertaining to my background for employment or volunteer purposes.  I hereby fully release and discharge my prospective employer or other source providing information from all claims and damages arising out of or relating to any investigation of my background for said purposes.
I understand that nothing in this employment application, in Camp White Eagle/Camp Kupugani policy statements or personnel guidelines or in any communication with any Camp White Eagle/Camp Kupugani Official is intended to create an employment agreement with me.  No promise regarding employment has been made to me, and I understand that no such promise or guarantee is binding upon Camp White Eagle/Camp Kupugani unless it is made in writing and signed by the director.
In the event of my employment with Camp White Eagle/Camp Kupugani, I will comply with all rules, regulations and policies set forth in Camp White Eagle/Camp Kupugani’s Personnel Policy or other communications distributed by Camp White Eagle/Camp Kupugani.  I understand that Camp White Eagle/Camp Kupugani has the right to modify its policies without giving me any notice of the changes.  I understand that if an employee relationship is established, I have the right to terminate my employment at any time for any reason without penalty.  I also understand that Camp White Eagle/Camp Kupugani retains the right to terminate my employment at any time for any reason with or without cause.
Applicant's Signature (enter your name)
Today’s Date:
What number should we call to speak with you concerning Staff Possibilities?
When is the best time of day to call you?
I HEREBY STATE THAT THE FOREGOING INFORMATION IS TRUTHFUL AND ACCURATE AND IS TO BE CONSIDERED AN INTEGRAL PART OF ANY CONTRACT I MAY ENTER WITH CAMP WHITE EAGLE / CAMP KUPUGANI

Camp Kupugani

6903 W. White Eagle Rd., Leaf River, IL 61047 | email: info@campkupugani.com
Toll-free: 866-471-4616 | Phone: 815-713-4110 | Fax: 815-738-2764

Camp White Eagle

6903 W. White Eagle Rd., Leaf River, IL 61047 | email: info@campwhiteeagle.com
Phone: 815-738-2754

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