Summer Job Application

Personal Information
First Name:
Middle Initial:
Last Name:
Age:
Sex:	Female Male
Permanent Address:
Permanent City:
Permanent State:
Permanent Zip:
Permanent Country:
College Address:
College City:
College State:
College Zip:
College Country:
Preferred Mailing Address :	College Permanent
Daytime Phone:
Nighttime phone:
Email:
Fax:
Job Information
First Job Choice:
Second Job Choice:
Can you work the whole summer?	Yes No
If not, please explain why:
Level of Education:
College Major:
What is your experience working with people with disabilities?
Work History
Employer #1
Business Name:
Contact Person:
Phone Number:
Employer #2
Business Name:
Contact Person:
Phone Number:
Employer #3
Business Name:
Contact Person:
Phone Number:
References Please list one of each:
Personal: (other than family)
Name:
Phone:
Work / School
Name:
Phone:
Why do you want to be a part of the Camp Joy team?
What gifts and talents would you bring to Camp Joy?
What dates and times are you available for an interview?	Date #1: Please select 3 times on this date you are available: Time #1: Time #2: Time #3: Date #2: Please select 3 times on this date you are available: Time #1: Time #2: Time #3: Date #1: Please select 3 times on this date you are available: Time #1: Time #2: Time #3:
Will distance from the camp warrant a telephone interview?	Yes No
Camp Joy is a smoke-free environment. Smoking is prohibited on Camp Joy grounds.
ACKNOWLEDGEMENT By executing this employment application... I authorize the release to Camp Joy of any document or information within the possession of a third party, such as an educational institution or licensure board, that may serve to verify any representation I have made in this employment application. I also acknowledge that state licensing regulations requires a Pennsylvania State Police Criminal History check, Pennsylvania Child Abuse History, National Sexual Offender check and Department of Aging FBI background check for all camp personnel and these background checks will be completed prior to employment. I expressly authorize, without reservation, the employer, its representatives, employees or agents to contract and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me. I understand that Camp Joy is a tobacco-free facility and will refrain from using tobacco in any form while on duty and/or on Camp Joy property. I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered.
AFFIRMATIVE ACTION - VOLUNTARY INFORMATION Camp Joy / Brian's House, Inc needs to comply with governmental requirements and we ask for your assistance to do so. Providing this information is STRICTLY CONFIDENTIAL and VOLUNTARY. Failure to provide it will NOT subject you to any adverse personnel decision or action. EEO Self-Identification Please check the box (only one) that applies to you Hispanic or Latino White Black or African Native Hawaiian or Other Pacific Islander Asian American Indian or Alaska Native Two or More Races