Regional YMCA of Western Connecticut
Greenknoll Summer Camp Employment Application
please close this window after completion
Name: SS#:
Home Address: City:
State: Zip: Home Phone:
College Name:
College Address:
College Phone:
Emergency Contact Name:
Emergency Phone Number:
How did you learn about employment at the Regional YMCA?
Advertisement YMCA Employee YMCA Vacancy The Internet Other
Have you ever worked for
The Regional YMCA?  Yes No 
Are you a U.S. Citizen?  Yes No  
If No, what type of Visa do you have? 
Alien Registration Number: Expiration Date:
Please check the position that you are applying for:
Young Tribe counselor
(Pre-K through 1st Grade)
Old Tribe counselor
(2nd through 4th Grade)
Oldest Tribe counselor
(5th through 8th Grade)
Lifeguard/Swim Instructor
(Certifications must be current through September)
Unit Leader
(Must be 18 years or older)
If you indicated Sports/Specialty Camp, which sport or specialty?
Are you able to work the entire summer?  Yes   No
Please list the dates that you are NOT available (No conflict, type OK):
Volunteer Service - Please list all experiences (if no experience, enter none):
Hobbies - Please list any training, skills, certifications, or special experience which
would further qualify you for the position:
Mark any that you have an interest in:
Archery Hiking/Camping Athletics Fishing Woodworking
Theater Music Nature Arts/Crafts Swimming
Other (please explain):
Who was your favorite teacher/counselor and why? 
Why do you want to work for the Regional YMCA summer day camps? 
What special skills do you believe you can offer the children at camp?
If you attended camp as a child, what was your favorite memory?
What was your least favorite activity and how would you change/improve it?
How would you handle a situation in which a camper didn't like or want to participate in a specific activity?
Personal References (you must provide at least 2):
Name: Occupation:
Address: Phone:
Name: Occupation:
Address: Phone:
Name: Occupation:
Address: Phone:
Employment References:
Name: Occupation:
Address: Phone:
Name: Occupation:
Address: Phone:
Name: Occupation:
Address: Phone:
High School (name and address):
Curriculum: Major:
Did you graduate? Yes No 
Awards & Honors?
(if still in High School, also type "still attending")
College (name and address):
Did you graduate? Yes No  Awards & Honors?
Degree: Major:
Specialized courses:
You must answer each of the following questions:
Do you authorize us to secure confidential reports on your performance
and ability from your former employer(s)?
  Yes No
Other references?  Yes No
Your present employer?  Yes No(if not employed at the present time, you may skip this question)
Have you ever been convicted of a criminal offense
(felony or misdemeanor, except for a minor traffic violation)?
  Yes No
Please explain (if no felony or misdemeanor, type "None"):
Is there litigation pending?  Yes No
Please explain (if no pending litigation, type "None"):

The above information is true and complete to the best of my knowledge.  Should I be employed by the Regional YMCA of Western Connecticut, any misrepresentation, false statements, or omission contained herein will be considered cause for dismissal.  The YMCA has my permission to obtain all necessary information from the references I have listed, or any other source, concerning my prior employment or personal history and release all parties from possible damages resulting from disclosing such information with or without prior written notice by me.
   The Regional YMCA of Western Connecticut may terminate my employment at any time at it's discretion, with or without cause and with or without prior notice.
   I further understand that should I be employed, such employment with the Regional YMCA of Western Connecticut is provisional pending completion of a criminal record check, reference check, and verification of other data.

I fully understand and wish to have my application considered (must be checked)
For security reasons and for your protection, and also before we can process your application, we will verify by e-mail and/or phone call that this application has indeed been filed by the party listed.

E-mail Address:   Daytime Phone #:

Thank you for applying to the Regional YMCA of Western Connecticut Day Camp Program

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