<p> Camp Kum-Ba-Yah CIT Application 4415 Boonsboro Rd. Lynchburg, VA 24503 434 384-1755 [email protected]</p><p>We consider applicants without regrd to race, color, religion, gender, national origin, non-camp related medical condition or handicap.</p><p>PERSONAL DATA Name ______Date of Birth ______Last First Middle Month Day Year</p><p>Permanent Address ______Street City State Zip Telephone ( ) ______Email ______</p><p>Name of Parent or Guardian ______</p><p>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.</p><p>______</p><p>______</p><p>______</p><p>______</p><p>Leadership courses taken ______</p><p>Work or volunteer experience ______</p><p>______</p><p>QUESTIONS FOR PERSONAL REFLECTION</p><p>1. Why would you like to be a Counselor-In-Training? ______</p><p>______</p><p>______</p><p>______2. What contribution do you feel you can make to the camp program? ______</p><p>______</p><p>______</p><p>______</p><p>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.</p><p>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:</p><p>CAMP EXPERIENCE Dates Camp Director Name and Address:</p><p>Name and Address:</p><p>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. </p><p>Name Address Phone Relationship H.( ) W.( ) H.( ) W.( ) H.( ) W.( )</p><p>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.</p><p>______CIT Signature Date</p><p>______Parent or Guardian Signature Date</p>