Counselor Application FormAll prospective counselors must fill out this form for each week or weekend camp event.NOTE: Social Security Number is REQUIRED only for those 18 years of age or older. If you are younger than 18, enter "n/a". Counselor Information Name * First Name Last Name Social Security Number * This is needed for all counselors 18 years of age or older in order to run background checks. Should fit the format of 123-45-6789. Gender * Male Female Email Address * Home Phone * (###) ### #### Cell Phone (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Expected High School Graduation Year (if HS age or younger) * Not in High School 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 Experience & Interests Experience Please list any experience with camping, counseling, and/or working with developmental disabilities. Talents Please list any special talents or interests you would like to contribute to New Day. Parent or Guardian Information If under 18, please fill out. Guardian Name Guardian Home Phone (###) ### #### Guardian Cell Phone (###) ### #### Guardian Work Phone (###) ### #### Emergency Contact Information Emergency Contact Name * First Name Last Name Relationship to Applicant * Emergency Contact Home Phone * (###) ### #### Emergency Contact Work Phone (###) ### #### Emergency Contact Cell Phone (###) ### #### Emergency Contact Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Medical Information Doctors Name * First Name Last Name Doctors Phone * (###) ### #### Doctors Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Medical Insurance Carrier * Medical Insurance Policy Number * Medical Conditions Please list any medical conditions. Allergies Please list any allergies. Medications Please list any medications and dosage of each (please note that ALL medications must be clearly labeled and stored with the nurse upon arrival, REGARDLESS OF AGE). Who referred you to New Day (returning counselors enter "Returning")? * Thank you! Your application was received and you will be contacted shortly!