Lake Greeley Camp - Medical Staff Application

Section 1. General Information:

First Name:

Gender:

Last Name:

Social Security # :

- -

Email Address:

Date of Birth:

Current Address

Street:

City:

State:

Phone:

Zip:

Permanent Address

Street:

City:

State:

Phone:

Zip:

What is the best time to reach you? :

Height:

Weight:

How did you hear about Lake Greeley Camp? :

Earliest Date Available

Latest Available Date

Do you Smoke:

Do you Swim:

Year in College:

College Major

Are you married?

Are you currently taking any RX drugs for a medical condition or recurring disease?:

Will any children be coming to camp with you?

If yes, number of children:

Children's Details
	Age	Sex		Age	Sex
Child 1			Child 4
Child 2			Child 5
Child 3			Child 6

Is your spouse interested in working at camp? If yes, please indicate what your spouse would like to do at camp ?

Do you have a valid driver's license?

If yes, what is the state and licence # :

State:
Licence #:

Can you drive a 15 passenger van?

If yes, what is the extent of your experience:

Do you have any dietary restrictions? If yes, please explain

Do you have any condition that may limit your ability to perform your duties as a member of our medical staff?

Nursing positions are for 4 weeks in the summer.

1st Half (June 26-July 22) or 2nd Half (July 23-August 18)

Please indicate your preference:

1st Half:

2nd Half:

Either Session:

Salary Desired

Please keep in mind that room, board & laundry services are provided.

Red Cross Certifications

First Aid			Lifeguard
CPR			WSI
lifeguard Instructor			First Aid responder

What other certifications do you hold that might have bearing upon camp employment?

Please indicate the medical certification you hold:

Please indicate the medical certification held by you:	RN	LPN	EMT	MD	DO
How many years have you held this certification?:
In what states are you licensed?:
Is the license current?: Expiration Date:

Section 2. Education:

College	Major	Yrs. completed as of June '07	Degrees Granted

Section 3. References and Employment:

Reference 1:
Name:		Day time phone #:


Street:

		Evening phone #:
City:


State:
		Relationship:

Zip:

Reference 2:
Name:		Day time phone #:


Street:

		Evening phone #:
City:


State:
		Relationship:

Zip:

Reference 3:
Name:		Day time phone #:


Street:

		Evening phone #:
City:


State:
		Relationship:

Zip:

If you have worked at a camp previously, please complete the following information for each camp employment.

Camp Director Reference 1:
Name:		Camp Name :
Street:		Job Held:
City:		Camp Phone #:
State:		Start Date:
Zip:		End Date:
Position held and responsibilities assumed:

Camp Director Reference 2:
Name:		Camp Name :
Street:		Job Held:
City:		Camp Phone #:
State:		Start Date:
Zip:		End Date:
Position held and responsibilities assumed:

Camp Director Reference 3:
Name:		Camp Name :
Street:		Job Held:
City:		Camp Phone #:
State:		Start Date:
Zip:		End Date:
Position held and responsibilities assumed:

Medical Employment (non-camp) Experience

Date	Employer	Street Address	City, State, & Zip

Nature of Work

Date	Employer	Street Address	City, State, & Zip

Nature of Work

Date	Employer	Street Address	City, State, & Zip

Nature of Work

PROFESSIONAL SKILLS AND EXPERIENCE:

In the section below we ask that you describe the extent of your medical experience. We would like to know the areas of medicine in which you have worked, the extent of your knowledge with respect to emergency medical care and first aid, as well as your experience in treating and caring for children.

Have you ever been convicted of any crime, including sex related or child abuse related offenses?

If yes, please explain in detail:

SUMMER: 222 Greeley Lake Rd, Greeley, PA 18425 p. 570.685.7196
WINTER: P.O. Box 219, Moscow, PA 18444 p. 570.842.3739