<p> 2010 STAFF APPLICATION</p><p>Name:______Social Security#:______</p><p>Permanent Address:______street city state zip School Address(if different than above):______street city state zip Phone number(s): Home:______Cell:______E-mail address:______Birth Date:______/______/______Age as of August 31, 2010______month day year In emergency, contact______name and relationship phone Present Occupation:______Level of education completed by June 15, 2010______school or college ______major yr. completed degree Indicate any condition(s) that would restrict your work:</p><p>Do you have a criminal record or have you been arrested for child abuse/sexual assault? If yes, explain:</p><p>Do you have a current driver’s license?______yes/no number state Do you have health insurance? ______Will you be present for the entire camp season (July 1 – August 3)? Yes or No______How did you learn about Maine Arts Camp?______Previous Camp Experience:</p><p>Dates:______Camp Name______Position______</p><p>Dates:______Camp Name______Position______Other Youth related Experience:</p><p>Dates:______Organization______Position______</p><p>Dates:______Organization______Position______</p><p>From the activity list below, name up to 5 activities in order of your interest to teach. For each activity, rate your ability to teach, from 1-5, 5 being the highest (able to lead the activity) and 1 being the lowest. Fine Arts: Technology: Individual sports: printmaking robotics tennis metal jewelry videography archery pottery rocketry mountain biking sculpture digital photography kayaking/canoeing painting/drawing fitness batik yoga stained glass Dance: ultimate frisbee mask making jazz martial arts fabric arts modern fencing sewing choreography road biking enameling tap beading ballet Special Interests: hip hop gardening Theater: culinary arts improvisation Music: environmental education acting chorus chess theater tech guitar creative writing playwriting flute/woodwind/brass bridge building</p><p>1.______2.______3.______4.______5.______</p><p>For those activities you can lead, list your relevant background/experience:</p><p>Any other activities of interest? Why are you interested in working at Maine Arts Camp?</p><p>Current qualifications, certifications, licenses? ____First Aid _____C.P.R ______Lifeguard training ______W.S.I. _____Archery _____A.R.C. Small craft/canoe ______USPTA/USPTR ______PGA Other(s)______</p><p>References (Professional, Educational, Occupational)</p><p>1.______name phone relationship 2.______name phone relationship 3.______name phone relationship</p><p>By signing this application, you are giving Maine Arts Camp the right to do a background check. Signature:______Date:______</p><p>Please return this form to the winter address below: Maine Arts Camp P.O. Box 812076 Boca Raton, FL 33481 Phone: 561-865-4330 Fax: 561-865-0855 E-mail: [email protected]</p>