CIT Application - Formstack

	Fernwood Cove CIT Program Application
	First Name*
	Last Name*
	Address*
	City*
	State*
	Zip Code*
	Country
	Applicant Email Address*
	Camper Session* One Two

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	Parent Contact Information
	Parent 1 Name*
	Parent 1 Complete Address (if different from above)
	Parent 1 Email Address*
	Parent 2 Name
	Parent 2 Full Address (if different from above)
	Parent 2 Email Address*
	I live with:* Parent 1 Parent 2 Both Parents Other: Other Value

	Applicant Information
	Date of Birth* Month Day Year
	Final Day of Current School Year* (This is the date on the current school calendar. It is understood that this date may change to to state testing, snow days, etc.)
	Do you speak a foreign language? Yes No
	If yes, which?
	Do you have any special dietary needs? Yes No
	If yes, explain:
	If accepted into the CIT program you will be required to be in camp from the beginning of the first session through the end of second session. Can you make that commitment?* Yes No
	If no, explain:

	Experience with Children Please list any experience you have had working with kids. This includes: employment (babysitting included), volunteer position, school or community organization, and family or neighborhood experience.
	Experience Type Volunteer Paid Employment Other
	Age of Child/Children
	Amount of time in experience If this is an experience you've had multiple times you can add all of the hours together. An approximation is fine.
	Description of Responsibilities
	Experience Type Volunteer Paid Employment Other
	Age of Child/Children
	Amount of time in experience If this is an experience you've had multiple times you can add all of the hours together. An approximation is fine.
	Description of Responsibilities
	Experience Type Volunteer Paid Employment Other
	Age of Child/Children
	Amount of time in experience If this is an experience you've had multiple times you can add all of the hours together. An approximation is fine.
	Description of Responsibilities

	Employment History Please list your employment history not already listed above.
	Job Title
	Employer
	Employer Phone
	Dates Worked
	Supervisor (if different from employer)
	Job Responsibilities/Description
	May we contact this employer? Yes No
	Job Title
	Employer
	Employer Phone
	Dates Worked
	Supervisor (if different from employer)
	Job Responsibilities/Description
	May we contact this employer? Yes No
	Job Title
	Employer
	Employer Phone
	Dates Worked
	Supervisor (if different from employer)
	Job Responsibilities/Description
	May we contact this employer? Yes No

	Athletic Teams Please list any school/community athletic teams you currently play on or have played on in the past 2 years.
	Athletic Team #1
	Position
	Year(s) Participated
	Athletic Team #2
	Position
	Year(s) Participated
	Athletic Team #3
	Position
	Year(s) Participated

Fernwood Cove CIT Program Application

	Other Extracurricular Activities
	List all clubs, organizations and non-sport teams you have been involved in within the past 2 years:
	List any leadership positions you have held in the activities listed above:
	List any awards, honors or other recognition that you have received:

	Volunteer Experience Have you ever volunteered? If yes, please list any experience not listed above.
	Volunteer Position #1
	Organization
	Number of hours completed
	Job Responsibilities/Description
	Volunteer Position #2
	Organization
	Number of Hours Completed
	Job Responsibilities/Description
	Volunteer Position #3
	Organization
	Number of Hours Completed
	Job Responsibilities/Description

	Certifications Do you have any of the following certifications?
	First Aid Yes No
	If yes, list the expiration date Month Day Year
	Certifying Body
	CPR Yes No
	If yes, list the expiration date Month Day Year
	Certifying Body
	Lifeguard Training Yes No
	If yes, list the expiration date Month Day Year
	Certifying Body
	List any other certifications that you have and the expiration date(s):

	Activity Experience Rate your experience in the following activities using the following scale: 1 = No Experience; 2 = Little Experience; 3 = I've participated at camp; 4 = I participate regularly; 5 = I've taught this to others
	Mountain Biking*
	Nature*
	Outdoor Living Skills*
	Rock Climbing*
	Ropes Course*
	Archery*
	Basketball*
	Field Hockey*
	Lacrosse*
	Soccer*
	Softball*
	Tennis*
	Volleyball*
	English Riding*
	Natural Horsemanship*
	Other riding style*
	Aerobics*
	Yoga*
	Cheerleading*
	Ballet*
	Hip Hop/Street*
	Jazz*
	Tap*
	Contemporary/Modern*
	Scripted Theater*
	Musical Theater*
	Stage Production*
	Guitar*
	Piano*
	Trumpet/Bugle*
	Vocal Performance/Singing*
	Arts & Crafts*
	Ceramics*
	Drawing*
	Painting*
	Photography*
	Sewing/Fabric Arts*
	Jewelry/Silver Smithing*
	Cooking*
	Canoeing*
	Crew/Rowing*
	Kayaking*
	Sailing*
	Swimming*
	Wakeboarding*
	Water Skiing*
	List any other activities in which you have experience
	List any Mini Course activities in which you could assist
	List any new activity ideas that you have

	In Your Own Words... Please answer the following questions. If you need additional space email your responses to alicia@fernwoodcove.com.
	Why do you want to be at CIT at Fernwood Cove? Why do you feel you would be a good addition to the CIT Program*
	What are your expectations of the CIT Program? (What do you expect to experience, learn, gain, etc. if you are a part of the CIT Program?)*
	What do you feel would be your biggest challenge as a CIT?*
	What does the phrase "Extraordinary World" mean to you?*
	Complete the following: Fernwood Cove is a place...*

	References In addition to this application you are required to have three (3) written references. References should come from non-family members. School counselors, coaches, teacher, religious and community leaders make excellent references. Camp Counselors can be used as a supplemental 4th reference if you'd like. Download the reference form from the Fernwood Cove website or give your reference(s) the link to the online reference form. Ask references to return (mail, fax, email) the complete reference forms to camp by October 1.

	Fernwood Cove Policies HEALTH FORM: It is our policy that all CITs are expected to have a health examination form completed by their physician prior to camp. ILLEGAL DRUGS/ALCOHOL/TOBACCO: It is our policy that the use of and/or possession of any kind of illegal drugs, illegally obtained prescription drugs, alcohol or tobacco products are prohibited by CITS while under the care of Fernwood Cove and is reason for immediate dismissal from camp. Fernwood Cove is not responsible for returning any tuition or fees paid for a CIT who is sent home due to violation of this policy. CIT PROGRAM PARTICIPATION: The Fernwood Cove CIT Program is a 3-year program, allowing CITs to participate in the program for up to three years or until they become eligible to be a counselor, whichever comes first. Participation in the CIT Program is not required for Fernwood Cove Alumni to become counselors, nor does participation in the CIT Program guarantee employment at Fernwood Cove as a counselor or otherwise.

	Certification of Truthfulness & Policy Acknowledgement The information provided is true to the best of my knowledge.  I understand the above stated policies and that failure to comply with any and all Fernwood Cove policies may result in a termination of my position as a CIT at Fernwood Cove.
	Certification of Truthfulness & Policy Acknowledgement* I agree to the statement above I do not agree to the statement above
	Date of Application (today's date)* Month Day Year