Medomak Staff Application-2018
Contact Information
First Name *
Your answer
Last Name *
Your answer
Social Security Number (111-22-333) *
Your answer
Permanent Address *
Your answer
Permanent Address City *
Your answer
Permanent Address State *
Permanent Address Zip Code *
Your answer
Phone Number *
Your answer
Fax Number
Your answer
E-Mail address *
Your answer
School or Business Name
Your answer
School or Business Address
Your answer
School or Business City
Your answer
School or Business State
School or Business Zip Code
Your answer
School or Business Phone Number
Your answer
School or Business E-Mail
Your answer
General Information
Start Date Available *
MM
/
DD
/
YYYY
End Date Available *
MM
/
DD
/
YYYY
What type of position do you want at camp? *
Your answer
What is your desired salary? *
Your answer
Do you meet or exceed any minimum age requirements for that position? *
Can you perform the essential functions of the job for which you have applied, with or without reasonable accommodation? *
If you are hired would you desire or need housing for any person(s) other than yourself at the camp? *
Past Work History
Provide a full record of all employment — paid and volunteer — and explain any gaps in employment. Include any positions on camp staff. Use provided extra space , if necessary.

Please use format below:

Date Employed, Employer Name, Address & Phone Number, Nature of work, Reason for Leaving

Past Work History #1
Your answer
Past Work History #2
Your answer
Past Work History #3
Your answer
Past Work History #4
Your answer
Past Work History #5
Your answer
Please use the space below to add any additional information on your past work experiences
Your answer
Indicate any employer you do not wish us to contact, and the reason
Your answer
References
Give names and contact information of three persons [not relatives] having knowledge of your character, experience, work habits, and ability.

Use Format Below:

Reference Full Name, Relationship, Phone Number & E-mail
Reference #1 *
Your answer
Reference #2 *
Your answer
Reference #3 *
Your answer
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