Camp Lohikan's Medical Staff Application

* Required Information

Section 1. General Information:

Name:
E-Mail Address:

Current Address:
Street:
State:
Town:
Zip:
County:

Permanent Address:
Street:
State:
Town:
Zip:
County:

Current Phone:
Work Phone:

Best time to reach you:
Social Security Number.
Gender:

Is your spouse interested in working at camp? If yes, please indicate what your spouse would like to do at camp:
Do you have children that you will be bringing to camp?
No. of Kids:
   
   
Age
Sex
  
Age
Sex
 
Child 1:
Child 4:
Age & Sex of Children:
Child 2:
Child 5:
 
Child 3:
Child 6:

Do you have a valid driver's license?
If yes, what is the state and #:
Can you drive a 15 passenger van?
If yes, what is the extent of your experience:

How did you learn about Camp Lohikan:
 
Search Engine?
 
 
Website Directory?
 
 
Other Source?
 

Earliest starting date available:
 
Month/Day/Year
Latest ending date available:
  
 
Month/Day/Year
Requested Compensation for period of availability.
(Please keep in mind that room, board & laundry services are provided and our camp season covers 50 work days and a one week orientation.)

Do you have any dietary restrictions? If yes, please explain:

Do you smoke?
Are you currently taking any RX drugs for a medical condition or recurring disease?
Do you swim?

Do you have any condition that might limit your ability to watch over/safeguard children or are there any reasons you may have difficulty in performing any of the essential elements of being a camp staff member? If yes, please explain.


Section 2. Skill/Certification Areas:

Please check all certifications/licenses held by you.
Nursing-RN
Nursing-LPN
Nursing-EMT
CPR
First Aid
Advanced First Aid
Wilderness First Aid
First Aid Responder
Nurse's Assistant
CNA
Doctor-MD
Doctor-DO

Please indicate how long you have held the above certifications/licenses.
 
Please indicate other certifications you hold that might have bearing upon your camp employment.


What is the extent of your medical experience?
 
 
What is the extent of your experience providing medical care to children?
 
 
What is the extent of your summer camp experience?
 
Kindness is very important at Camp Lohikan. A camp staffed with role models who exemplify kindness on a daily basis creates an ideal environment for children and adults to thrive. Can you give us an example of a simple act of kindness you performed recently?
 

Section 3. Character References:

Please list names and telephone numbers of 3 people (not relatives) who have knowledge of your abilities, experience and character.

 

Reference 1:
Name:
Day time phone #:
Street:
City:
Evening phone #:
State:
Zip:
Relationship:

 

 
Reference 2:
Name:
Day time phone #:
Street:
City:
Evening phone #:
State:
Zip:
Relationship:

 

 
Reference 3:
Name:
Day time phone #:
Street:
City:
Evening phone #:
State:
Zip:
Relationship:

Section 5. Previous Camp Employment:

If you have worked at a camp previously, please complete the following information for each camp employment.
 
Camp Director Reference 1:
Name:
Camp Name :
Street:
Job Held:
Town:
Camp Tel#:
State:
Start Date:
Zip:
End Date:

 

 

Camp Director Reference 2:
Name:
Camp Name :
Street:
Job Held:
Town:
Camp Tel#:
State:
Start Date:
Zip:
End Date:

 

 

Camp Director Reference 3:
Name:
Camp Name :
Street:
Job Held:
Town:
Camp Tel#:
State:
Start Date:
Zip:
End Date:

Section 4. Employment History: Please list your employment for at least the past 3 years.

 

Date

Employer

City and State

Nature of Work

 

Have you ever been convicted of child abuse or a sexual abuse offense?

 

Have you ever been accused or convicted of a felony or misdemeanor?   If yes, please explain:

 

The statements made in this application are true, complete and correct. I understand that any misrepresentation of information shall be considered sufficient reason for withdrawal of an application with Camp Lohikan.

I hereby authorize Camp Lohikan or its authorized representatives bearing this release or copy thereof to obtain any information pertaining to my employment, military, credit, criminal, driving record, workers compensation claims, or educational records, including but not limited to information concerning academic achievement, attendance, disciplinary actions, criminal or civil court records, credit and driving history, character, work habits, performance, experience and reasons for termination of past employment. I hereby direct you to release such information at the request of Lohikan or its representatives.

By electronic submission of this application to Camp Lohikan, I understand and agree to the conditions set forth above.