BERKSHIRE HILLS - EMANUEL CAMPS
Staff Application

NAME _________________________________________  SS # __________________

ADDRESS _______________________________________________________________ 

CITY ________________________________________  STATE ____  ZIP ________

DATE OF BIRTH _________________   TELEPHONE # _________________________  

EMAIL ADDRESS _________________________________________________________

EDUCATIONAL EXPERIENCE:  HIGH SCHOOL GRADE ______   COLLEGE YEAR ______

COLLEGE ADDRESS _______________________________________________________

                __________________________________  TEL # _____________

POSITION APPLYING FOR _________________________________________________

COUNSELOR EXPERIENCE (References must be provided):

 1. ___________________________________________________________________

 REFERENCE ____________________________________________________________
          Name                Address                  Tel #

 2. ___________________________________________________________________

 REFERENCE ____________________________________________________________
          Name                Address                  Tel #

 3. ___________________________________________________________________

 REFERENCE ____________________________________________________________
          Name                Address                  Tel #

SPECIAL SKILLS OR TALENTS _____________________________________________

HOW DID YOU HEAR ABOUT OUR CAMP? ______________________________________

AVAILABILITY: FROM _______ TO _______  SALARY REQUESTING ______________

Have you ever been arrested, indicted or accused of any form of child 
abuse or of any form of behavior that might be considered inappropriate 
for someone who will be working with children?  YES ____    NO _____

SIGNATURE ______________________________________  DATE ________________

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FOR OFFICE USE ONLY:  Position ___________________  Salary ____________