Staff Application

Personal & Contact Information

Name*

First Last

Social Security #

Address*

Street Address City State ZIP Code

Home Phone*

Cell Phone

Email*

School Name (if applicable)

School Address (if applicable)

Street Address City State ZIP Code

School Phone (if applicable)

Birth Date*

Marital Status

Gender

Educational Background

High School*

Graduation Date*

College 1

Graduation Date

Major(s)

College 2

Graduation Date

Major(s)

Grad / Professional School

Graduation Date

Major(s) / Degree(s)

Current School Year*

Employment History

Most Recent or Current Position

Name of Business

From

To

City & State

Supervisor

Weekly Salary

Positions

Phone

Reason for Leaving

2nd Most Recent Position

Name of Business

From

To

City & State

Supervisor

Weekly Salary

Positions

Phone

Reason for Leaving

3rd Most Recent Position

Name of Business

From

To

City & State

Supervisor

Weekly Salary

Positions

Phone

Reason for Leaving

Experience With Children

Please list all experience with children in school, clubs, etc.

Camp or School Experience
Please list all camp or school experience as both an employee and/or a camper.

Most Recent Experience

Name of Camp or School

Years Employed / Attended

Supervisor

Weekly Salary

Positions

2nd Most Recent Experience

Name of Camp or School

Years Employed / Attended

Supervisor

Weekly Salary

Positions

3rd Most Recent Experience

Name of Camp or School

Years Employed / Attended

Supervisor

Weekly Salary

Positions

Extracurricular Activities
Please list the extra-curricular activities (sports, theatre, etc) in which you are or have been involved with. Kindly include hobbies and/or community service.

High School Activities

College Activities

Credentials & Certificates

First Aid

Standard First Aid*

Yes
No

First Aid for Coaches*

Yes
No

Responding to Emergencies*

Yes
No

Water Safety Instructor*

Yes
No

Nassau County Lifeguard Certification*

Yes
No

American Red Cross Lifeguard Training*

Yes
No

Certifications

CPR For The Professional Rescuer*

Yes
No

Training In The Use Of A Defibrillator*

Yes
No

Commercial Driver License*

Yes
No

If you have any of the above certifications, please list the expiration dates.

Park Shore Day Camp Experience

I would like to work at:*

Camp
School

Check all that apply

Camp Positions*

Please check all positions you might be interested in

School Positions*

Teacher
Teaching Assistant
Specialist
Bus Driver
Maintenance

Please check all positions you might be interested in

Please list any special talents you would like to let us know about:

If you are hired to work in a group at camp, what is your preference? (Please place your choices in order from most desired to least desired.) We will try our best to follow the order you select, however, please understand there is no guarantee.

Select 1st Choice*

Select 2nd Choice*

Select 3rd Choice*

List any camp or school aged children you may have, indicate their names, genders, and ages:

If you were referred to Park Shore by someone please list his/her name and your relationship:

References
Please do not use family members or friends as references. We would like objective recommendations from all references. Please include name, address, phone number, and relationship.

Reference 1

Name*

First Last

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Relationship*

Reference 2

Name*

First Last

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Relationship*

Reference 3

Name*

First Last

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Relationship*

Background History
Have you ever been arrested, indicted, or convicted for any of the following: Please answer all.

Child Abuse*

Yes
No

Sexual Abuse*

Yes
No

Drug Possession*

Yes
No

DWI*

Yes
No

DUI*

Yes
No

If yes to any of the above, please be specific as to the dates, reasons, and outcomes:

Optional: Upload Resume / Cover Letter

Cover Letter

Resume

NOTE: ALL EMPLOYEES UNDER 18 YEARS OF AGE WILL ALSO BE REQUIRED TO SUBMIT VALID WORKING PAPERS. (NOTE: THIS IS A NYS LAW) ALL EMPLOYEES UNDER 21 YEARS OF AGE MUST HAVE A BIRTH CERTIFICATE ON FILE IN OUR OFFICE. (OUR OFFICE WILL MAKE A COPY) By clicking on the submit button you are in essence providing your signature and certify that all the information provided on this application is true and free of falsehood as well as giving the permission to conduct a background check. In the event that the applicant is hired, the terms of this application shall be incorporated into and become part of your employment agreement.

It is Park Shore’s policy that you will not be discriminated against or harassed because of your race, color, natural origin, sexual orientation, genetic information about an applicant/employee, citizenship status, religion, age, sex, disability, veteran status, marital status, political affiliations or any other protected status.

Digital Signature*

I Agree To The Terms Above

Name

This field is for validation purposes and should be left unchanged.

Employment Application

Most Recent or Current Position

2nd Most Recent Position

3rd Most Recent Position

Experience With Children

Most Recent Experience

2nd Most Recent Experience

3rd Most Recent Experience

First Aid

Certifications

If you are hired to work in a group at camp, what is your preference? (Please place your choices in order from most desired to least desired.) We will try our best to follow the order you select, however, please understand there is no guarantee.

Reference 1

Reference 2

Reference 3