Address: ________________________________________________________________________

Phone Number: ___________________________________________________________________

Education: Name of School, Year Graduated and Major

High School: ______________________________________________________________________

College/University: ________________________________________________________________

Graduate/Professional: _____________________________________________________________

Other: Vocational, etc. _____________________________________________________________

Circle Classification: High School Senior College: Freshman, Sophomore, Junior, Senior, Graduate

Certifications and Expiration Date:
WSI: _________________ Archery: ________________ Teaching: ____________
Life Saving: ___________ CPR: ___________________ Other: _______________
First Aid: _____________ Climbing/Ropes: __________ Other: _______________

Answer the following questions. Feel free to attach additional sheets if necessary.

1. Why do you want to work for Sertoma 4-H Educational Center?

2. What contributions could you make to Sertoma 4-H Educational Center?

3. List extracurricular Activities.

4. What experiences have you had working with Children?

5. Please have three letters of reference written by non-family members mailed to Sertoma 4-H Educational Center.

Affirmations

The 4-H camping Program's objective is to be a strong, positive influence on campers who are developing their personal habits and values. A counselor's example is most important in achieving this objective. Accordingly, I understand and agree to abide by the 4-H camp expectations regarding the use of illegal drugs in any form, the use of alcoholic beverages or tobacco, and the necessity of maintaining good personal habits of conduct, grooming, and hygiene.

I have never been convicted of any offense against the law or forfeited collateral, nor am I now under charges for any offense against the law. (You may omit: 1) traffic violations; and 2) any court or under a Youth Offender Law.) A conviction will not necessarily disqualify you. Please attach explanations, if appropriate.

North Carolina law requires notice to every applicant for state employment that willfully providing false or misleading information or falling to disclose relevant information shall be grounds for rejection of an application, later disciplinary action up to and including dismissal, or criminal prosecution. Dismissal from employment shall be mandatory in any case, in which a false or misleading representation is made in order to meet position qualifications.

By executing this employment application, I authorize the release to North Carolina State University of any document or information within the possession of a third party, such as an educational institution or licensure board, that may serve to verify any representations I have made in this employment application.

___________________________________________
SignatureDate

References
Please list at least 3 references we may contact regarding your ability to work effectively in this camping program. Please do not list family members as references.

NameAddressPhone number Relationship
1.
2.
3.

Employment and program opportunities are offered to all people regardless of race, color, national origin, sex, and or disability. North Carolina State University, North Carolina A&T State University, U.S. Department of Agriculture, and local governments cooperating.