Staff Application
"Camp Clot Not"

Note: "Camp Clot Not" is an equal opportunity Camp. Applicants for camp staff will not be discriminated against on the basis of race, sex, age, national origin, creed, or disability.

* Required

If you have questions regarding this application or the application process, please contact Vicki Jackson at the
HBDA Office at (334) 277-9446.

Title
First Name *		Last Name *

Email Address *		Date of Birth *
Home Address *		Home Phone Number * (include area code)
		Cell Phone Number (include area code)
City *	State *	Zipcode/Postcode *
Country *
Enter Word Verification in box below *
The above information may be included on a list to be distributed to all Camp Staff Members* Yes No
High School Education		College
Current Employer		Current Supervisor and Phone Number (include area code)
Employer Address		City, State, Zipcode
Ever Attended Camp as a Camper? Yes No		If Yes, list: Camps
Below List any camps where you served as staff, and the position you served.
Camp, Position		Camp, Position

Summarize additional experience in working with youth		Would you be interested in developing or leading an activity at camp? If so, what would that activity be, in detail.

What age group do you prefer to supervise?
Current Certification Water Safety Lifeguard CPR EMT Nursing		What Capacity to participate
Availability all week Yes No
Do you have bleeding disorder Yes No		If Yes type & severity
Below please provide 2 references, personal or professional that do not include relatives.
First Reference *
Address *
City, State, Zipcode, Phone *
Second Reference *
Address *
City, State, Zipcode, Phone *
Have you ever been arrested for a crime* Yes No
Convicted Yes No
Acknowledge Signature *
Social Security *
Drivers License or ID Number *

Staff Application "Camp Clot Not"

Staff Application
"Camp Clot Not"