Summer Youth Camp Application

Your Name *

Social Security Number *

Address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Email *

Home Phone *

Cell Phone *

Birth Date *

Gender *

MaleFemale

Emergency Contact Name *

Emergency Contact Phone *

Do you plan on taking a vacation this summer *

YesNo

If yes, list the dates

Are you a licensed driver? *

YesNo

If yes, What is your drivers license number

If no, how will you get to the camp

How did you Hear about the camp *

InternetCareer FairSchool Teacher/OfficialLibraryNewspaper ArticleOther

Have you previously interned at CTV or attended the summer youth camp? *

YesNo

If yes what year?

List previous summer jobs, camps, and volunteer experience?

School Name: *

Student ID# *

City: *

State: *

Zip Code: *

Grade level *

Are you in good academic standing *

YesNo

You may be asked to provide transcripts and other schooling information as verification.

What is your GPA? *

How many days were you absent from school last year? *

If required by your school have you completed your community service hours *

YesNo

Have you ever been convicted of a crime? You may ommit any juvenile offenses but please list all offenses where you were adjudicated as an adult *

YesNo

If yes please list date, charges, and punishment for crime

A conviction does not automatically mean that you cannot be considered. The nature and date of the conviction are important. Give all the facts so that a decision can be made.

Answering yes does not mean automatic ommision from camp

Do you have any medical conditions that could prevent your from full participation? *

YesNo

If yes, please explain

Please include a one or two page essay explaining why you want to participate in the camp *

Summer Youth Camp Application

Fieldset

Applicant Information

Education

Other Information

Verification