ODE Counselor Application

Name*

First Middle Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Shirt Size

Work Experience

Company Name	Dates Worked	Position	Address	Job Duties	Supervisor	Supervisor Phone Number

Education*

Name of High School	Current Grade Level	School Address

Activities: School Clubs, Leadership, AVID, Extracurricular Activities

Skills: Please list any skills or additional trainings

Musical Instruments or Talents: Let us know what you can do!

Certifications: Please list all current certifications and include expiration date (ex. CPR, First Aid, AED)

Have you had any traffic violations in the last three years? (If yes, please explain)

Have you ever been convicted of a felony, excluding misdemeanors and summary offenses, which has not been annulled, expunged or sealed by a court? (If yes, please explain)*

Reference #1*

Full Name	Relationship	Address	Phone	Email

Reference #2*

Full Name	Relationship	Address	Phone	Email

Reference #3*

Full Name	Relationship	Address	Phone	Email

I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without previous notice. I hereby give Western Camps, Inc. permission to contact schools, all previous employers (unless otherwise indicated), references, and others, and hereby release Western Camps, Inc. from any liability as a result of such contact.*

I Agree

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