2019 Panthers Camp - Leadership Application
This is an application for a leadership opportunity with Panthers Camp, summer 2019. To apply, please complete the online form.

All applications are due by 2/20/19.

The first year leadership is a Junior Counselor in Training (JCIT) - entering 8th grade is the minimum requirement. The second year leadership is a Junior Counselor in Training 2 (JCIT2) - entering 9th Grade is the minimum requirement. The third year leadership is a Junior Counselor (JC) - entering 10th grade is the minimum requirement.

The fee to participate in this program is as follows: as a JCIT, the cost of the program is $200; as a JCIT2, the cost of the program is $150; as a JC, there is no cost to the program. This cost covers facilities management costs.

Please contact Dan Flahavan if you have any questions - pantherscamppv@gmail.com.

Email address *
Applicants Last Name *
Your answer
Applicants First Name *
Your answer
Applicants Cell # *
Please include area code. Insert N/A if not applicable.
Your answer
Applicants Email *
Please enter your private email.
Your answer
Applicants Birthday *
MM/DD/YY
Your answer
Grade *
Entering in August 2019
Leadership *
Weeks Available to work *
Required
Weeks you Prefer to work *
Required
Work Hours: 8:10 - 3:10. *
Please mention any issues you may have with working these hours (eg. leaving early, etc.)
Your answer
Extended care is offered daily from 3:00-5:30. *
Are you available to work?
Shirt Size *
Address *
Street, City, ZIP
Your answer
Parent/Guardian Information
Parent/Guardian 1 *
First and Last Name
Your answer
Cell Phone *
Please include area code. Insert N/A if not applicable.
Your answer
Home Phone *
Please include area code. Insert N/A if not applicable.
Your answer
Work Phone *
Please include area code. Insert N/A if not applicable.
Your answer
Email address *
Your answer
Parent/Guardian 2 *
First and Last Name
Your answer
Cell Phone *
Please include area code. Insert N/A if not applicable.
Your answer
Home Phone *
Please include area code. Insert N/A if not applicable.
Your answer
Work Phone *
Please include area code. Insert N/A if not applicable.
Your answer
Email address *
Your answer
Emergency & Health Information
Emergency Name *
First and Last Name
Your answer
Emergency Contact Phone *
Please include area code.
Your answer
Health Insurance Carrier *
Your answer
Group/ID Policy # *
Your answer
Waiver
The following Waiver (District Release, Hold Harmless, Medical Release, Photo Consent) is required for Participation. Without exception, failure to sign this permissions slip will preclude participation in Panthers Camp.

I want my daughter/son/legal charge to participate in Panthers Camp.


DISTRICT RELEASE: With my signature below, I acknowledge that the Panthers Camp (Camp) is neither sponsored nor endorsed by the Portola Valley Elementary School District (District) and I hereby release the District from any potential liability emanating from the programmatic operation of this Camp.

HOLD HARMLESS: I, the undersigned, parent or guardian, do hereby agree to allow the individual(s) named herein to participate in Panthers Camp and I further agree to indemnify and hold harmless Dan Flahavan and the Panthers Camp Staff from and against any and all liability for any injury which may be suffered by the aforementioned individuals arising out of or in any way connected with participation in this camp program.

MEDICAL RELEASE: In the case of a medical emergency, I give permission to Dan Flahavan and the Panthers Camp Staff to order treatment for my child. This includes any medical treatment or x-rays.

PHOTO CONSENT: I give consent for photos/videos of my child to be used in promotional materials, camp publications, & website postings. I understand campers will not be identified by name on any promotional materials or photos unless additional permission has been granted by the parent/guardian.

Applicant Electronic Signature *
Selecting "Yes" will serve as my authorization and signature.
Required
Parent Electronic Signature *
If under 18 years old, you need a parent signature. Selecting "Yes" will serve as my authorization and signature.
Required
Signature Date *
Your answer
Thank you for applying for a leadership position at Panthers Camp.
Now that you have submitted the online form, please submit the program fees. In order to have a complete application, all fees are due by 2/20/19. For JCIT, submit $200. For JCIT2, please submit $150. No fees for JC position.

Please send fees to this address:
Panthers Camp
1875 Walnut Dr.
Mtn. View, CA. 94040

Panthers Camp is looking for individuals who display leadership qualities, integrity and responsibility. Application to the program does not guarantee placement. Checks will be returned if you are not accepted.

All applications will be processed and notices of hire will be sent out by April 15th or sooner.

Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service