Pre-Placed Application


Camp Name: *
Camp Director's Name: *
Camp Phone Number:
Camp Fax Number:
Camp Email:
Your Position at Camp: *
Personal Information (as it appears on your passport)
First Name: *
Middle Name
Last Name: *
Date of Birth: *	Month Day Year
Earliest date you can fly to the U.S. *	Month Day Year
Latest date you can stay in the U.S. *	Month Day Year
Gender: *	Male Female
Country of citizenship: *
Country of legal residence: *
City of birth: *
Country of birth: *

Applying for: (select only one and complete the rest of the application accordingly) *
Counselor Support Staff

Are you a student? * (If answering yes, you must also answer the next 4 questions)
Yes No
What type of student are you?
Name of school:
Field of study:
Anticipated graduation date: (month/year)	Month Day Year
If you are not a student, please provide us with information about your job:
Name of current employer/company:
Position/Occupation:
Length of employment:

Have you ever participated in an exchange program in the U.S.?If yes, please list all of the programs you have participated in, with the most recent program first. *
YesNo
Name of camp/school/workplace:
Position:
Name of sponsoring organization:
Dates participated (month/day/year):

Name of camp/school/workplace:
Position:
Name of sponsoring organization:
Dates participated (month/day/year):

Name of camp/school/workplace:
Position:
Name of sponsoring organization:
Dates participated (month/day/year):

Correspondence Information
(please enter the address in your home country where we should send the sponsorship paperwork)
Street Address: *
City: *
State, Province:
Postal Code:
Country: *
Either a home or mobile telephone number is required. *
Phone: (with country and city codes)
Mobile Phone (with country and city codes)
Email: *
Emergency Contact (English-speaking)
First Name: *
Last Name: *
Relationship to you: *
Street Address: *
City: *
State, Province:
Postal Code:
Country: *
Phone: (with country and city codes) *
Email: *

Friend/Family Contact in the United States
Do you have a friend or family in the U.S.? * If you answer yes you must enter the following information.
Yes No
First Name:
Last Name:
Relationship to you:
Street Address:
City:
State:
Zip Code:
Phone (with country and city codes)
Email:

Medical History
Are you in good health? *	Yes No
Height (feet) * Conversion Information
Height (inches)* Conversion Information
Weight (in pounds) *Conversion Information
Do you have any physical disabilities? *	YesNo
If yes, please describe:
Do you have any dietary restrictions? *	YesNo
If yes, please describe:
Have you ever or are you currently suffering from an eating disorder? *	YesNo
If yes, please describe:
Do you have any allergies or special medical requirements? *	YesNo
If yes, please describe:
Have you ever suffered from a nervous breakdown or mental disorder? *	YesNo
If yes, please describe:

Visa History
Have you ever applied for a United States visa before? *	YesNo
If yes, from what country did you apply?
What was the final decision of the U.S. Embassy/Consulate?
Passport number:

Past Experience
Please list two of your past jobs (paid or voluntary) and in 2 or 3 sentences describe how they will be relevant to your position at camp. *
Name of Company: *
Dates of Employment: *
Details: *
Name of Company:
Dates of Employment:
Details:

Camp Placement
Please list the position you will have at camp this summer, and in 3 or 4 sentences, describe your job responsibilities and/or daily role at camp.
Job Description *
To convert centimeters to inches: cm x .39 = inches 12 inches = 1 foot e.g. 180 cm x .39 = 70 inches or 5 feet, 10 inches To convert kilos to pounds: kg x 2.2 = pounds e.g. 70 kg x 2.2 = 154 pounds

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Pre-Placed Application

Personal Information (as it appears on your passport)

Correspondence Information

Medical History

Visa History

Past Experience

Camp Placement