Camp Kum-Ba-Yah

Camp Kum-Ba-Yah CIT Application 4415 Boonsboro Rd. Lynchburg, VA 24503 434 384-1755 [email protected]

We consider applicants without regrd to race, color, religion, gender, national origin, non-camp related medical condition or handicap.

PERSONAL DATA Name ______Date of Birth ______Last First Middle Month Day Year

Permanent Address ______Street City State Zip Telephone ( ) ______Email ______

Name of Parent or Guardian ______

LEADERSHIP AND CHILD CARE EXPERIENCE Please provide us with a list of positions of responsibility and leadership you have held including but not limited to: any club memberships, sports teams, band, child care, household chores, etc. Be sure to include what position you held in each.

______

Leadership courses taken ______

Work or volunteer experience ______

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QUESTIONS FOR PERSONAL REFLECTION

1. Why would you like to be a Counselor-In-Training? ______

______

______2. What contribution do you feel you can make to the camp program? ______

______

SKILLS If you have any training, experience, expertise, or certification in any of the following areas, please indicate below. Rating 1= Those activities you can organize, teach, and work with competently. 2= Those you can assist in teaching. 3= Those you can participate with some ability.

Arts and Crafts Waterfront Performing Arts Handicrafts Swimming ability: Song Leading Macramé Poor Dance Sketching Fair Storytelling Weaving Good Acting (skits) Wood Excellent Mime Leather Clowning Pottery Outdoor Education Other Painting Ropes Course: Nature Crafts Low Elements Music Tye Dyeing High Events Piano Painting Outdoor Cooking Guitar Environmental Activities Singing Languages Other Other: Please list languages:

CAMP EXPERIENCE Dates Camp Director Name and Address:

Name and Address:

Name and Address: REFERENCES: Please provide the following information about two teachers and one other adult individual who can attest to the quality of your work performance.

Name Address Phone Relationship H.( ) W.( ) H.( ) W.( ) H.( ) W.( )

RELEASE OF INFORMATION We authorize without liability investigation of all the statements in this application. We further authorize those references listed with whom we are acquainted to furnish Camp Kum-Ba-Yah Inc. with information used in connection with the evaluation of the above named applicant for admission to the Counselor In Training (CIT) Program.

______CIT Signature Date

______Parent or Guardian Signature Date