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Please return the completed application to the following address:
Contact: Duane Hanson or Phil Bramley
312 Wisconsin Avenue, Madison, WI 53703
608.257.3577  Fax: 608.257.4044
bhorizons@bethel-madison.org   www.bethel-madison.org

BETHEL HORIZONS OUTDOOR MINISTRIES APPLICATION

AN ELCA CAMPING PROGRAM

Name ________________________________________          Date Of Application _______________

Birth Date________________Male ____ Female____    Social Security Number ___________________

Home Address___________ __________________________________________________________

City ___________________________ State_________  Zip __________  Phone (___ )___________

School Address _____________________________________________________________________

City ___________________________  State________ Zip ___________ Phone (___ )_________

Place an "X" before the address at which you can be reached most easily.

Home congregation ___________________________________  E-Mail:________________________

What is your present school/college grade or class level? ___________________________________

Where are you currently attending school? _____________________________________________

What is your current major? _________________________________________________________

List schools you have attended                           Year attended                     Degrees received

____________________________________      _________________            ___________________

___________________________________        _________________            ___________________

Have you been in the military? _____________   Which branch? ______________________________

Dates you were in the service___________________________  Do you have reserve duty? _________

What was your rank at discharge? ______________________________________

Employment History: (List your last two jobs)

1. Employer __________________________________________________________

Address  ______________________________________________________    Phone  (____)__________

Job Title ________________________________  Dates employed ______________________

2. Employer ____________________________________________________________

Address _______________________________________________________   Phone  (____)___________

Job Title ________________________________  Dates employed _______________________

3. Please give the name, address, and telephone number of two references who are not related to you and are not previous employers.

_______________________________________________________________________________________

_______________________________________________________________________________________

4. If you have worked on a summer camp staff, please list the camp, positions held, and the dates of employment. ___________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

1. Have you ever been convicted of a felony?    Yes______         No ______

2. Is there any circumstance in your background which would call into question your being entrusted with the supervision, care or guidance of youth?          Yes______          No_______

3. Have you ever been accused of sexual misconduct or abuse? (If yes, please explain.)  Yes_____     No_____

4. Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Yes_____       No______

What positions do you wish to apply for? Please use a numbering system to rank the positions in order of preference. (Begin with "1" as your top preference)

___ Camp Counselor                                           ___ Lifeguard (requires certification)
___ Food Service Director                                    ___ Camp Cook
___ Naturalist                                                     ___ Program Director
___ Maintenance Staff/Driver                                ___ Health/Nurse (requires certification)
___ Wilderness Counselor/Guide                          ___ Artist 

Do you currently hold any instructor level certificates such as Water Safety Instructor, Lifeguard Instructor, Boating Instructor?  If so, please list type and dates of expiration:

If applying for positions of health supervisor or camp nurse please answer the following questions:

Are you a registered nurse?________       Emergency Medical Technician? _______
American Red Cross Emergency Response ________

Other certificates that might qualify you for this position:

What states are you registered to work in?  ___________,   ___________,   ___________,   __________

Camp skills and Interests: (Check those area in which you feel you could provide some leadership to youth campers.)

What kind of instruments can you play?

What types of arts and crafts do you enjoy?

What special hobbies can you share at camp?

What groups have you belonged to, or do you presently belong to? (Note any leadership positions held.)

What kind of experience should young people encounter at camp?

What special contribution do you think you can make at Bethel Horizons?

How do you feel you can best express your Christian faith at Bethel Horizons?

Write a biographical sketch including reflections on any camping experiences you might have had and any other background which might have a bearing on this application.

What date would you be available to work?  ____________________________

Please submit at least one reference within two weeks of application.

We consider applicants for all positions without regard to race, color, sex, national origin, age, marital or veteran status, the presence of a non job-related medical condition or handicap, or any other legally protected status.