Return by January 12, 2007 to:
*Please type or print neatly
I am applying for:
______ 4-H Camp Counselor _______ Cloverbud Camp Counselor
OSU Extension, 111 S. Nelson Avenue, Wilmington, OH 45177
(to be a camp counselor
for Clinton County)
Name ______________________________________ Phone ______________________________
Address ___________________________________________ City _________________________
State _______ Zip _________ Gender _____Male ______Female Date of Birth ___________ Age ____
E-mail address _________________________ Do you check e-mail daily? __ Yes ____ No
School _____________________________ Grade _____________
Number of years you have attended camp as a camper? ______ What did you like most about being a camper?
_________________________________________________________________________________________________
Number of years you have been a counselor? ______ Why do you want to be a counselor? ____________________
_________________________________________________________________________________________________
What do you feel are your strengths (skills) for being a camp counselor? ____________________________________
_________________________________________________________________________________________________
What leadership activities have you participated in (may include activities other than 4-H?) _______________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
References: These should be adults (not relatives) who have seen you working with other youth. Examples: 4-H Club Advisor, Teacher, Employer). The Extension Office will contact your references. Please provide complete information below.
1. Name __________________________ Address ________________________________________________________
City _______________________ State ___________ Zip code _____________ Phone _______________________
2. Name __________________________ Address ________________________________________________________
City _______________________ State ___________ Zip code _____________ Phone _______________________
3. Name __________________________ Address ________________________________________________________
City _______________________ State ___________ Zip code _____________ Phone _______________________
All educational programs
conducted by Ohio State University Extension are available to clientele
on a nondiscriminatory basis without regard to race, color, creed, religion,
sexual orientation, national origin, gender, age, disability or Vietnam-era
veteran status.