YMCA-International Camp Counselor Program

Transcription

1 YMCA-International Camp Counselor Program Recruiter Code: ESPA APPLICATION Must Be Typed. Personal Information (Enter all information exactly as it appears on your passport) All programs of the International YMCA are open to eligible applicants on an equal opportunity basis. Information requested on this form is required solely to maximize each applicant s placement options. FAMILY NAME: FIRST: MIDDLE (full spelling): Date of Birth: / / Age (as of May 1) Sex: Male Female City of Birth: Mo. Day Year Country Country Country of Birth: of Citizenship: of Permanent Residency: PERMANENT ADDRESS (to be reached at all times- cannot be a Post Office Box) Street Are you a student? Yes No / University Other Post Secondary Name of University: Degree Program: Country Telephone Alternate Telephone Country code/city code/number Country code/city code/number Name of Post Secondary Institution: Name of Certificate Program: If Not a student, what is your current occupation? Name of current employer: Do you smoke? Yes No Are you prepared not to smoke at camp? Yes No When is the best time to contact you? Monday-Friday AM/PM At Noon In New York, what time is it in your country? 18:00 AM/PM The earliest date I can arrive to the US between May 11 th and June 22 nd is: The latest date in August that I must return home is Month/Day/Year Camp Preference: All are resident camps except for day camps. Camp for physically/mentally challenged See Special Needs Supplement Page 12 I will accept only a program position (counselor) I will accept only a support staff position Resident Camp Day Camp Religious Girl Scout Day Camp I will accept a program OR a support staff position *Support Staff will be placed at any camp My Strongest Five (5) Camp Skills are: My Strongest Five (5) Support Skills are: Certifications: Please attach copies of any relevant certifications

2 Skills: (attach additional pages if necessary) Please describe your experience related to each of the strongest skills identified on the first page. State where and with whom you have learned each skill. Remember to attach copies of current certifications. You may include pictures. Additional Skills: Please use this space to describe any relevant experience that you may have in additional camp related categories listed on page 2.

3 Summer Camp: Why have you decided to work at a camp this summer? What previous camp experience do you have? What will you share culturally at camp? What will you do this summer if you do not work at a camp? What one thing would you like us to know about your country? Personal Values As a participant of a YMCA program, regardless of your placement site, you will be a role model to everyone with whom you have contact. As such, you are expected to model positive values, such as Caring, Honesty, Respect and Responsibility. Please describe your own personal values. If you have indicated that you would accept a placement at a Religious Camp, please discuss the role of religion in your life.

4 Personal Attribute What are your strongest qualities? What personal characteristic would you like to improve? Do you prefer to work alone or with a group? How would you describe yourself to someone who does not know you? Leadership What leadership/volunteer positions have you held? Are you a member of the YMCA or YWCA? Have you been a Boy Scout/Girl Guide/Scout Leader? If yes, for how long? Have you previously worked in a camp in your home country? Yes No If yes when? Have you previously worked on a J-1 summer work/travel program in the US? Yes No When? Have you previously worked at a US summer camp? Yes No Number of years? If yes, which organization sponsored your J-1 visa? If yes, which camp? Would you like to return to the same camp? If not, please include a reference from your former US camp director and explain why you would like to go to a new camp. Personal Background Have you ever been convicted of a crime? YES NO Have you ever been convicted of child abuse? YES NO Have you ever been denied a visa to the United States? YES NO Do you have relatives in the U.S. If yes, Name: Address: Telephone:

5 DEAR CAMP DIRECTOR: SIGNED:

6 International Camp Counselor Program HEALTH HISTORY Name: Sex: M F Age: Address: Country Code: City Code: Telephone: IN AN EMERGENCY PLEASE NOTIFY: Name Address Country Code City Code Telephone: TO THE PHYSICIAN: This person will serve up to four months in the USA as a leader in summer camp for children or as support staff in the kitchen, office, or maintenance department of a summer recreational facility. Your careful examination and written recommendations will encourage physical wellness and safe participation in strenuous activities. HEALTH HISTORY: (Please indicate YES or NO and give approximate dates) DISEASE YES NO DATE DISEASE YES NO DATE DISEASE YES NO DATE Asthma Fainting Rheumatic Fever Malaria Heart trouble Hepatitis Chicken Pox Measles Seizures Convulsions Mumps H.I.V./A.I.D.S. Diabetes German Measles ALLERGIES YES NO DATE Hay Fever Insect Stings Poison Ivy Penicillin Other Drugs Operations for serious injuries Chronic or recurring illnesses Other diseases or details related to the above Do you currently have a medical condition requiring the regular intake of medication? Yes No If yes, please list: Any history of emotional or mental disturbances? Yes No Have you ever suffered from an eating disorder? Yes No If yes, provide separate description. (For women) Is menstrual history normal? Yes No If no, are there any special considerations to be made? (For women) Are you pregnant? Yes No

7 Health History Form must be completed by a licensed physician. The physician must determine applicant s fitness to engage in strenuous activities. Please indicate whether the following are satisfactory (S), unsatisfactory (U) or not examined (NE): Eyes Lungs Skin Glasses Heart Allergy (please specify) Ears Hernia Nose Abdomen Throat Extremities Genitalia Posture (Spine) IMMUNIZATION HISTORY: Please record dates of basic immunizations. Required immunizations are determined by each U.S. state. Participant should ask U.S. site director which are required. Polio Typhoid Diphtheria Tetanus Tuberculin Test Mumps Measles Measles Rubella (German Measles) Other General Appraisal: Special Diet: Are you a vegetarian? Are you presently or have been in the last two years on any medication? If yes, explain Any Restrictions On: Swimming/Diving Camping/Hiking Strenuous activity in sports Other Do you smoke? Yes No If yes, are you prepared not to smoke on camp premises? Do you have any visible tattoos or body piercing? If yes, please explain Do you consume alcoholic beverages? Yes No If yes: Daily occasions Weekly Every 2 weeks On special FOR PHYSICIAN: I have examined this person and have reviewed the health history. It is my opinion that this person is physically able to engage in strenuous activities, except as noted above. Signature of licensed examining physician Date Telephone: Address: FOR PARENTS OF PARTICIPANTS UNDER 21 YEARS OF AGE: In the event that I cannot be reached in an emergency, I hereby give my permission to the physician selected by the U.S. site director to hospitalize, secure proper treatment for, and to order injections, anesthesia or surgery for my child as named above. Signature of parent Date FOR THE NURSE OR PHYSICIAN AT U.S. SITE: Each ICCP participant has been provided with an Illness and Accident Insurance claim form, which he/she will bring to the placement site. This form may be filled out and sent directly to the Insurance Company along with all bills pertaining to the illness or injury. Please note: There is a deductible on sickness claims.

8 International Camp Counselor Program Reference Form This reference questionnaire should be completed by a teacher, coach, tutor, employer, priest, minister, rabbi. References from family members or friends will not be accepted. Your name as reference: Address: Signature: Date: Phone: E Mail: Name of applicant: What is your relationship to the applicant? If you have employed applicant, in what capacity? How long have you known the applicant? When was your last contact with the applicant? Please rate the personality and suitability of the applicant for the camp position applied for. Attitude Adaptability Responsibility Resourcefulness Enthusiasm Leadership Initiative Patience Sense of Humor Cooperation Excellent Good Fair Poor Based on your experience, how well does the applicant relate to other people? What would you consider to be the applicant s best program skills and personality strengths for working at camp? How well do you think the applicant could teach these skills at camp? Would you employ the applicant to teach these skills and work with children? Is this a translation? Yes No Address

9 International Camp Counselor Program Reference Form This reference questionnaire should be completed by a teacher, coach, tutor, employer, priest, minister, rabbi. References from family members or friends will not be accepted. Your name as reference: Address: Signature: Date: Phone: E Mail: Name of applicant: What is your relationship to the applicant? If you have employed applicant, in what capacity? How long have you known the applicant? When was your last contact with the applicant? Please rate the personality and suitability of the applicant for the camp position applied for. Attitude Adaptability Responsibility Resourcefulness Enthusiasm Leadership Initiative Patience Sense of Humor Cooperation Excellent Good Fair Poor Based on your experience, how well does the applicant relate to other people? What would you consider to be the applicant s best program skills and personality strengths for working at camp? How well do you think the applicant could teach these skills at camp? Would you employ the applicant to teach these skills and work with children? Is this a translation? Yes No Address

10 International Camp Counselor Program Reference Form This reference questionnaire should be completed by a teacher, coach, tutor, employer, priest, minister, rabbi. References from family members or friends will not be accepted. Your name as reference: Address: Signature: Date: Phone: E Mail: Name of applicant: What is your relationship to the applicant? If you have employed applicant, in what capacity? How long have you known the applicant? When was your last contact with the applicant? Please rate the personality and suitability of the applicant for the camp position applied for. Attitude Adaptability Responsibility Resourcefulness Enthusiasm Leadership Initiative Patience Sense of Humor Cooperation Excellent Good Fair Poor Based on your experience, how well does the applicant relate to other people? What would you consider to be the applicant s best program skills and personality strengths for working at camp? How well do you think the applicant could teach these skills at camp? Would you employ the applicant to teach these skills and work with children? Is this a translation? Yes No Address

11 pay ICCP participant the amount specified in Pocket Money. No FICA or FUTA can be deducted from this amount as J-1 participants are exempt. The Pocket Money is the minimum net amount to be given to participants. Check with your State Labor Board to be sure that these amounts comply with the state minimum wage laws. The standard resident camp season is nine weeks (63 days) and the standard day camp season is eleven 5-day weeks (77 days), plus one week of staff training. The Pocket Money amount is based on these standard seasons (no pro-ration of the ICCP fee or Pocket Money will be given if camp contracts a participant for less than the standard ten weeks). For work beyond the ten weeks camps must pay ICCP participant the same wage that an American counselor would earn. The fee to ICCP and the Pocket Money to staff are calculated from the day after the staff member arrives at camp, including the staff training. However, if a participant arrives Earlier than the staff orientation for a certification-training course sponsored by the camp, their ten week contract will be effective on the first day of the camp s general staff orientation pay ICCP participant a partial flight refund, as determined by ICCP pay stipend, as determined by ICCP, to the participant for up to ten weeks of work (including staff training) pay a partial flight refund to participant, as determined by ICCP provide general liability insurance provide room & board or arrange home stay/host family (if a day camp) conduct evaluations The Applicant (Participant) will: provide accurate application information accept the placement arrangements made by ICCP promptly inform ICCP of cancellations, changes in application information or participant plans accept and abide by all the regulations of the Exchange Visitor Visa and return home prior to the expiration date on the visa comply with all camp rules, policies, regulations, performance standards be responsible for own expenses related to food and lodging if arriving to U.S. prior to the arrival date assigned by ICCP notify ICCP in writing of arrival to camp and of whereabouts when not on camp premises work at assigned camp for up to ten weeks (including camp training) for a minimum stipend (determined by ICCP) which is paid directly to participant by the camp. contact ICCP immediately concerning a serious camp problem, after first consulting with the camp director be responsible for own expenses related to all travel from camp at the end of the camp work assignment, and for all other personal expenses incurred from end of camp until return home in the event of early departure from the camp by an International staff person without proper notification, consultation and approval by ICCP, that person will reimburse ICCP for a pro rate amount of the ICCP service fee to be refunded to the camp ICCP may terminate this contract and send a participant home at the participant s expense in the event participant does not comply with the above terms be responsible for all expenses (food, lodging, travel) if employment is terminated by camp or if participant leaves camp before the end of the season until placed at another camp if it is so determined by ICCP staff Fees ICCP Application Fee (This fee is non-refundable if applicant is cancelled from the program) (Applicants rejected by ICCP will receive a $50 refund) $100 Scholarship $ Recruiter Fee $ Pocket Money will be (Minimum stipend for a total of 10 weeks including staff training) $ Flight Refund will be (Received only from Camp Director when contract has been $ successfully completed) Confirm Recruiter Fee and Flight refund with your recruiter before signing agreement. AGREEMENT: I have read, understand and agree to the above terms and conditions. Applicant s Name (Print): Date: Applicant s Signature: Country of residence: If applicant is under 21, parent or guardian must sign. Name of parent/guardian: Date: Emergency Contact Information Contact Person: Relationship to Applicant: Address: Telephone: Does this person speak English? 18 of 18