Staff Application Support Staff

4. Legal Name

4. Employer email 3

4. Social Security Number

4. Reference #1 (Please be sure to list their full name, email address, phone number and relationship to you.)

4. Reference #2 (Please be sure to list their full name, email address, phone number and relationship to you.)

4. Reference #3 (Please be sure to list their full name, email address, phone number and relationship to you.)

4. Address/Location 1

4. Address/Location 2

4. Address/Location 3

4. Date/Year employed 1

4. Date/Year employed 2

4. Date/Year employed 3

4. WORK/COMMUNITY SERVICE EXPERIENCE - Name of firm/agency/organization 1

4. Name of firm/agency/organization 2

4. Name of firm/agency/organization 3

4. Phone 1

4. Phone 2

4. Phone 3

4. Age/Sex of children

4. Are you available for an interview in New York?

   1. Yes
   2. No

4. Camp position for which you are applying

4. If not, what is your citizenship?

4. When?

4. Married/Domestic Partner?

   1. Yes
   2. No

4. Please state your approximate salary requirements

4. What are your previous experiences with community living? What do you regard as the challenges and benefits of living, working, and sharing closely with people for a summer?

4. U.S. Citizen?

   1. Yes
   2. No

4. Will family accompany you to camp?

   1. Yes
   2. No

4. Your Position 1

4. Your Position 3

4. Have you ever been convicted of any crime, including sexual abuse or a child abuse related offense? Yes No

4. If yes, please explain...(In accordance with the laws of Mass., we will be required to run a background check on you)

4. Degree/Diploma Received

4. Email 1

4. Email 2

4. Please describe your previous experience in this kind of work (if any)?

4. What do you enjoy about this work?

4. What about this work sometimes creates problems?

4. What do you think are your strongest skills in this type of work? Please be specific.

4. Year

4. Your position 2