Name______________________________________Sex M__F__

Date of Birth (D/M/Y)________________Heath Card #_____________________

Present Address_______________________________________(____)_____________

# Street City Postal Code Phone #

Permanent Address (if different from above)

_____________________________________________________(____)_____________

# Street City Postal Code Phone #

Are you legally eligible to work in Canada?________

Have you ever been convicted of a criminal offense for witch a pardon has not been granted?_________

Education

High School_____________________________Grade completed_________________

Post secondary___________________________Year/degree completed____________

Other ___________________________________

Employment

Present Employer_________________________Postion Held____________________

Phone # (_____) ______________ Direct Supervisor________________

Former Employers

________________________________________Position_______________Date______

________________________________________Position_______________Date______

Volunteer Work and Extracurricular Activities

1)______________________________________________________________________

Date(s) Organization Involvement Supervisor

2)______________________________________________________________________

Camping Experience

________________________________________________________________________

Date(s) Camp Position (camper/staff)

________________________________________________________________________

What experience do you have working with children?__________________________

________________________________________________________________________

Circle the Qualifications that you currently have. NLS, CPR, First Aid, OCRA

(Please send a photocopy of all your certificates after hiring)

What do you hope to get out of your camp experience?_______________________

______________________________________________________________________

Qualifications and areas of interest (note relevant experience for each program please include photo copies of awards) Rank your preference by number (#1 lots of experience and would like to lead this program through # 4 not as much experience but would like to give it a try)

Programs Experience Ranking

Available from_________________to____________________

References (former staff members leave this space blank and send a page with your ideas for next summer)

___________________________________________________Phone #(___)________

Signature______________________________Date___________________

Please return to: Andy Barnard (Cadotte)

Owen Sound Family Y

640 2^nd Ave east

Owen Sound , ON

N4K 2G8

(519) 376-0484 ext 221