Camp Millhouse 2016 Staff Application

25600 Kelly Rd. South Bend, IN. 46614 *(574) 233-2202 *campmillhouse@gmail.com

PERSONAL INFORMATION
Last Name_____________________________________ First Name____________________ Middle
___________________
S.S. # ___________________ Mailing Address
______________________________________________________________
Code)

(Street)

(City)

(State)

(Zip

Home Telephone________________________________ Alternate Telephone

_____________________________________
Cell Number: ______________________________ E-Mail Address______________________________________
Best time to contact you? ___________________ Best way to reach you (home, cell phone, email, etc)?
________________
Employment with Camp Millhouse requires you to be 16 or older. Do you meet that requirement
(circle one):
YES
NO
Permanent Address___________________________________________________
City_______________________________
State_____________________ Zip Code___________________
In case of an emergency, contact____________________________________
Relationship_____________________________
Home Telephone___________________________ Work Telephone______________________ Cell
__________________
Name of physician ________________________________ Phone number
______________________________________
Name of dentist _________________________________ Phone number
____________________________________
T-Shirt Size: _____________
Do you have access to dependable transportation?
__________________
****************************************************************************************************
*

Please check which position(s) you are applying for. If more than one position is
marked please specify order of preference with (1) being your first choice.
Health Care Staff
RN I would be able to work
Days Nights
No preference (Provide a current
copy of your nursing license)
LPN I would be able to work Days Nights
No preference (Provide a current
copy of your nursing license)
Graduate nursing student (must provide documentation)
Program Staff (Must be 18 years old or older)
Arts& Crafts Director
Recreation Director
Nature Director
Music Therapy
Life Guard (you need currant certification)
Kitchen Staff (Must be 18 years old or older to be a cook, 16 years old or older
to be a server)

Camp Millhouse 2016 Staff Application

25600 Kelly Rd. South Bend, IN. 46614 *(574) 233-2202 *campmillhouse@gmail.com

Cook (morning shift) generally 7 a.m. to 1 p.m.

Cook (afternoon shift) generally 1 p.m. to 7 p.m.
Server (morning shift) generally 7 a.m. to 1 p.m.
Server (afternoon shift) generally 1 p.m. to 7 p.m.

Cabin Staff
Counselor (Must be 18 years old or older)
Counselor-In-Training (C.I.T.) (Must be 16 years old or older)
Laundry (Must be 16 years old or older)
EDUCATION
List schools (high school and college, if applicable) you have attended and dates of attendance. Did
you complete core courses of study?
Name

Dates of Attendance

Major

Core courses

complete?
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____
WORK HISTORY
Please list the past five jobs you have held, starting with the most recent position.
Company Name

Dates Employed

Reason for Leaving

Supervisor
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
_____
May we contact your supervisor(s)?

Yes____ No____

VOLUNTEER EXPERIENCE
Please list all volunteer activities you have participated in within the past 5 years. You may list
older experiences if it is relevant to the position for which you are now applying.
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________

Camp Millhouse 2016 Staff Application

25600 Kelly Rd. South Bend, IN. 46614 *(574) 233-2202 *campmillhouse@gmail.com
____________________________________________________________________________________________________
_____
LEADERSHIP EXPERIENCE
List all the leadership positions you have held in school and/or with any organizations
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
___

Were you ever a Boy Scout or a Girl Scout? ______ Yes ______ No If yes when?
__________________________________
Have you ever worked at a summer camp? ____ Yes ____ No If yes where & when?
______________________________

CAMPING/OUTDOOR EDUCATION/LEADERSHIP TRAINING EXPERIENCE:

Name of Camp/Center

Position held

Dates
__________________________________

___________________________________

________________
__________________________________

____________________________________

________________
EXPERIENCE WITH PERSONS WHO HAVE SPECIAL NEEDS
Please describe to us any experience you have had with people who have special needs, including
where and when. What were the ages for the individuals with special needs and what were your
responsibilities as it related to these individuals?
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
_____
Please indicate the age group of those individuals with special needs with which you have had prior
experience. Check all that apply.
____ 4 - 7 ____ 8 - 12 _____ 13 - 18 _____ 18 - 25 _____ 25 older
If hired, part of your job (program and nursing staff, counselors, and CITs) will be to assist
those who need help with recreational activities and daily living skills. Please indicate your level of
experience for each item listed below. This will help us determine where we may need to provide

Camp Millhouse 2016 Staff Application

25600 Kelly Rd. South Bend, IN. 46614 *(574) 233-2202 *campmillhouse@gmail.com
training for staff. Experience (E), No experience (NE), willing to learn (WL)
Skill

NE but
WL

Pushing wheel chairs

Lifting people
Feeding individuals
Dressing individuals
Toileting individuals
Showering individuals
Changing/applying adult briefs
Shaving individuals
Brushing teeth of other individuals
Assisting persons with completing an activity
Outings with people who have special needs
Swimming with persons who need assistance
Observed a person have a seizure
Socializing with others who have special needs
Other areas where you may have experience (sign
language ex.).
Please explain:
____________________________________________________
____________________________________________________
____________

PERSONAL ASSESSMENT
1) What unique contribution or characteristic do you personally bring to the position for which you
are applying?

2) Describe your goals and/or objectives for the position for which you are applying.

3) What are your strongest qualities?

4) What are your weaknesses?

Camp Millhouse 2016 Staff Application

25600 Kelly Rd. South Bend, IN. 46614 *(574) 233-2202 *campmillhouse@gmail.com
5) Are you aware that this is a physically challenging job? i.e. Assisting with the lifting and
transferring of a camper, work in the sun, etc. Do you feel you are able to meet the
challenge?

6) Do you prefer to work alone or in a group? Why?

7) How would you describe yourself to someone who did not know you?

8) What do you imagine will be the greatest difficulty at Camp?

9) We want to provide our campers with a positive camping experience. What do you feel would
be important to provide a positive camp environment?

10) Is there any additional information you would like us to consider when reviewing this
Application?

PERSONAL HISTORY
Have you ever been arrested? ___Yes ___No If yes, a detailed explanation must be enclosed.
Have you ever been charged with or convicted of sexual abuse, assault, battery, neglect or
molestation? ___ Yes ___ No If yes, a detailed explanation must be enclosed.
REFERENCES
Please give the name, address, phone number and email of three persons not related to you
that we may contact as personal references. You must have known each of these individuals for at
least one year. We will send these individuals a reference questionnaire to complete.
Name

Address

Phone

Email
1.__________________________________________________________________________________________________
_2._________________________________________________________________________________________________
__3.________________________________________________________________________________________________
___

Camp Millhouse 2016 Staff Application

25600 Kelly Rd. South Bend, IN. 46614 *(574) 233-2202 *campmillhouse@gmail.com

I agree that the information provided on this Application is truthful to the best of my knowledge. I
understand and agree that if I have misled Camp Millhouse, Inc. with respect to the information
provided on my application and/or the information provided to a staff person I will be terminated
immediately.
Signature of applicant _____________________________________________ Date_________________________

You may submit your application via email at campmillhouse@gmail.com, fax at 574-233-2511 or
mail to Camp Millhouse, 25600 Kelly Road, South Bend, IN 46614. If you have any questions,
please call the office at 574-233-2202.