| Personal Information |
| I am over 18 Years Old |
| Name |
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Gender |
Male
Female |
| Social Security # |
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| Date of Birth |
4 digit year |
| Current Year in School |
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Driver's License # |
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| Home Address |
| Street |
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| City |
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State |
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| Zip |
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Country |
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| Phone |
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E-mail |
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| Secondary or School Address |
| Name of School |
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| Street |
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| City |
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State |
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| Zip |
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Country |
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| Phone |
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E-mail |
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| How often do you check your E-mail? |
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| If in College, Major |
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Career Goal |
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| Emergency Contact |
| Name |
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| Relationship to Applicant |
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| Phone (day) |
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Phone (evening) |
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| Cell |
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| Education, Training and Experience |
| School One |
| Name |
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| Address |
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| Days Attended |
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to |
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| Did you graduate? |
Yes
No |
Degree or Diploma |
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| School Two |
| Name |
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| Address |
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| Days Attended |
|
to |
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| Did you graduate? |
Yes
No |
Degree or Diploma |
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| School Three |
| Name |
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| Address |
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| Days Attended |
|
to |
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| Did you graduate? |
Yes
No |
Degree or Diploma |
|
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| Do you speak, write, or understand any foreign languages? |
Yes
No |
If yes, which language?
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Age Preference
(rank 1 through 3: 1 = highest, 3 = lowest) |
| Ages 7-9 |
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| Ages 10-12 |
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| Ages 13-15 |
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| How did you hear about us? |
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| Employment History |
| Employer One |
| Company Name |
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Supervisor's Name |
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| Employment Dates |
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To |
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| Phone |
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| Describe Work |
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| Reason for Leaving |
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| Employer Two |
| Company Name |
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Supervisor's Name |
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| Employment Dates |
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To |
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| Phone |
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| Describe Work |
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| Reason for Leaving |
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| Last camp employment or attendance |
| Camp Name |
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Camp Director |
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| Years at Camp |
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Street |
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| City |
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State |
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| Zip |
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Phone |
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| Please Check |
Counselor
Camper
Support Staff |
| References |
| List three references below. References should be from an employer, supervisor, teacher or coach - we will not accept references from co-workers, family members, or friends. Please send reference letters and camp-addressed envelope to your reference. They must mail the reference directly to us.
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| Reference One |
| Name |
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Address |
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| Phone |
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Relationship |
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| Reference Two |
| Name |
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Address |
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| Phone |
|
Relationship |
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| Reference Three |
| Name |
|
Address |
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| Phone |
|
Relationship |
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| Health Information |
| Realizing that camp counseling often involves extensive physical activity, please list any special conditions, problems or limitations, including physical or mental impairments, that might interfere with your ability to perform the job for which you are applying: |
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| Do you have any special dietary needs? |
Yes
No |
| Are you required to take any medications? |
Yes
No |
| If yes, please describe type and purpose: |
|
| Are you willing to obtain necessary certifications if you do not already have them? |
Yes
No |
| Camp Staff Profile |
| Please describe your race(s)/ethnicity(-ies)*: |
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| *Providing the information above is optional, yet it would be tremendously helpful if you did. Because we are addressing issues of difference, it is essential that we have a diverse group of cabin counselors. We not only strive for racial/ethnic diversity, but also for diversity of gender, socio-economic class, religion, culture, physical ability, personality, etc. This information will be used only to determine this balance. |
| Please describe any other ways by which you identify yourself (such as socio-economic class, religion, culture, physical ability, sexual orientation, background, etc.) that you would like to share with us: |
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| 1. How do you think children might benefit from a camp experience? |
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| 2. What do you perceive to be the responsibilities of a camp counselor? |
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| 3. Why do you want to participate in our camp? What do you hope to gain from the program? |
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| 4. How do you think you can contribute to the program? |
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| 5. Describe both leadership positions and any experience working with children, especially 7 – 15 year olds, if applicable. |
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| 6. Have you ever lived away from home for several weeks before? When? What do you foresee being your greatest challenge with the lifestyle at camp? How will you manage the challenges? |
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| 7. Please share a time when you experienced or witnessed prejudice or discrimination and how you dealt with the situation. |
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| 8. Describe what the word “multiculturalism” means to you. Please answer this question as if you are speaking to a 10 or 11 year-old. |
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| 9. Is there anything else you would like us to know about you? |
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| Camp Activities |
| On the following list, please put a number “1” at the left of those activities you could organize, coach and teach proficiently. You must be personally skilled and experienced. Put a number “2” by those activities you could actively assist in teaching. Put a “3” by those activities to which you have had some exposure. |
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| ADVENTURE |
ARCHERY |
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Low Ropes - Initiatives |
Archery |
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Rock Climbing Wall |
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Zip Line |
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| BIKING |
CANOEING |
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Biking |
Lake |
| |
Open water |
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| CRAFTS |
DANCE |
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Candle Making |
Aerobics / Hip Hop |
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Ceramics |
Ballet |
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Enamel |
Folk |
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Jewelry |
Jazz |
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Leather Craft |
Line |
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Macramé / Hemp |
Modern |
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Paper Crafts |
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Sketching |
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Tie Dye |
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Weaving |
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Woodwork |
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| DRAMA |
FISHING |
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Acting |
Fishing |
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Drama Production |
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Improv |
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Mime |
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Skits |
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Story telling |
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| FITNESS |
HIKING |
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Cross Training (Aerobics / Hand weights) |
Mountaineering |
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Karate |
Survival Skill |
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Kickboxing (Taebo) |
Trail Hikes |
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Personal Fitness |
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Self Defense |
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Step Aerobics |
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Tae Kwon Do |
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Yoga |
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| KITCHEN |
LANDSPORTS |
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Cooking |
Cricket |
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Baking |
Football |
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Food Prep |
Frisbee |
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Supervision / Mgmt. |
Playground Games |
| |
Soccer |
| |
Softball |
| |
Volleyball |
| |
Other
|
|
| LANGUAGES |
MUSIC |
|
French |
Guitar |
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Sign |
Lead Group Singing |
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Spanish |
Piano |
| Other
|
Solo |
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| NATURE / ECOLOGY |
OFFICE |
|
Animal Care |
Bookkeeping |
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Astronomy |
Data Entry |
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Geology |
PC Computer Skill |
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Plant & Animal Identification |
Secretarial |
| |
Typing |
| |
Web Development |
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| RIFLERY |
SWIMMING |
|
NRA Level |
Basic Water Safety |
| |
Competitive |
| |
Diving |
| |
Life Saving |
| |
Swimming |
| |
Water Games |
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| TEAMS |
OUTDOOR LIVING |
|
Low Ropes |
Backpacking |
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High Ropes |
Camping Skills |
|
Climbing |
GPS / Compassing |
|
Team Building |
Hiking |
| |
Knots |
| |
Orienteering |
| |
Outdoor Cooking |
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| OTHER |
|
|
Auto Mechanics |
|
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Campfire Programs |
|
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Carpentry |
|
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Conservation Work |
|
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Cooking |
|
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Creative Writing |
|
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Electrical |
|
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Juggling |
|
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Landscaping |
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| Other
|
|
| Name any additional skills that you could incorporate in the program. |
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| Current Certifications |
|
Required First Aid / CPR |
Date Received
|
|
Lifeguard Certification |
Date Received
|
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Water Safety Instructor |
Date Received
|
|
EMT |
Date Received
|
|
Wilderness First Responder |
Date Received
|
|
Wilderness First Aid |
Date Received
|
|
Riflery Instructor |
Date Received
|
|
Archery Instructor |
Date Received
|
|
Other |
|
| Important guidelines for Camp White Eagle / Camp Kupugani staff |
| As a staff member, you will be giving up a great deal of privacy and comfort, working long and demanding hours, adhering to camp policies which may be limiting (curfew, time on, time off, lack of privacy, etc.) |
| I understand and will adhere to the lifestyle change that camp may bring with it. |
Yes
No |
| Smoking: Smoking is not permitted on camp property at any time. |
| Will you adhere to this policy? |
Yes
No |
| Illegal Drugs: Possession of, being under the influence of, or being on camp property with any illicit drug like marijuana is not permitted and will result in immediate dismissal. All staff members are expected to be ready for work with campers anytime they are on camp or at a camp function. |
| Will you adhere to this policy? |
Yes
No |
| Alcohol: Absolutely NO alcoholic beverages may be brought onto camp property and no one may return to camp under the influence. |
| Will you adhere to this policy? |
Yes
No |
| Background Information |
| **If you answer “YES” to any of the following three questions, please indicate the convictions, location, police or court dates and circumstances. |
| 1. Have you ever been convicted of, or pleaded guilty to, a criminal charge of child abuse or sex related crimes? |
Yes
No |
If Yes, please explain:
|
| 2. Are you now under allegations for any violation of the law? |
Yes
No |
If Yes, please explain:
|
| 3. During the past ten years, have you been convicted, imprisoned, on probation or on parole (includes felonies, misdemeanors, firearms, or explosive violations and all other offenses)? |
Yes
No |
If Yes, please explain:
|
| Please read and initial beside each paragraph |
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I authorize Camp White Eagle/Camp Kupugani to investigate all statements in this application and to secure any necessary information from all my employers, references and academic institutions. I hereby release all those employers, references, academic institutions and Camp White Eagle/Camp Kupugani from any and all liability arising from their giving or receiving information about my employment history, my academic credentials or qualifications and my suitability for employment at Camp White Eagle/Camp Kupugani. |
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I further understand that any false or misleading statements will be sufficient cause for rejection of my application if Camp White Eagle/Camp Kupugani has not employed me and for immediate dismissal, if Camp White Eagle/Camp Kupugani has employed me. |
|
I hereby authorize Camp White Eagle/Camp Kupugani or authorized representatives of the company bearing this release to obtain and release any information pertaining to my background for employment or volunteer purposes. I hereby fully release and discharge my prospective employer or other source providing information from all claims and damages arising out of or relating to any investigation of my background for said purposes. |
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I understand that nothing in this employment application, in Camp White Eagle/Camp Kupugani policy statements or personnel guidelines or in any communication with any Camp White Eagle/Camp Kupugani Official is intended to create an employment agreement with me. No promise regarding employment has been made to me, and I understand that no such promise or guarantee is binding upon Camp White Eagle/Camp Kupugani unless it is made in writing and signed by the director. |
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In the event of my employment with Camp White Eagle/Camp Kupugani, I will comply with all rules, regulations and policies set forth in Camp White Eagle/Camp Kupugani’s Personnel Policy or other communications distributed by Camp White Eagle/Camp Kupugani. I understand that Camp White Eagle/Camp Kupugani has the right to modify its policies without giving me any notice of the changes. I understand that if an employee relationship is established, I have the right to terminate my employment at any time for any reason without penalty. I also understand that Camp White Eagle/Camp Kupugani retains the right to terminate my employment at any time for any reason with or without cause. |
| Applicant's Signature (enter your name) |
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| Today’s Date: |
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| What number should we call to speak with you concerning Staff Possibilities? |
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| When is the best time of day to call you? |
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| I HEREBY STATE THAT THE FOREGOING INFORMATION IS TRUTHFUL AND ACCURATE AND IS TO BE CONSIDERED AN INTEGRAL PART OF ANY CONTRACT I MAY ENTER WITH CAMP WHITE EAGLE / CAMP KUPUGANI |
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