2022 Junior Counselor Application Form

Page 1 of 3 - JC Applicant

Thanks for your interest in serving as a Junior Counselor (JC) at Wolfe's Neck Center! JC applicants must complete pages 1 and 2, and parent/guardians must complete page 3.

Please note: Priority consideration will be provided to complete applications received by April 15th.

We look forward to reviewing your application!

Junior Counselor's Information

Your First Name

Your Last Name

Nickname (if any)

Gender Pronouns

Date of Birth

Grade Entering in Fall 2020

Name of School

Your Email Address (we will share important programmatic information with you and your parent/guardian via email)

Camp T-Shirt Size:

Have you been a JC at Wolfe's Neck Farm Camp before?

Parent/Guardian Contact Info

Parent/Guardian 1 First Name

Parent/Guardian 1 Last Name

Relationship to JC

Mailing Address Street

City

State

Zip Code

Email Address

Preferred Phone

Cell Phone - format (207) 555-5555

Home Phone

Work Phone

Parent/Guardian 2 First Name

Parent/Guardian 2 Last Name

Relationship to JC

Mailing Address Street

City

State

Zip Code

Email Address

Preferred Phone

Cell Phone - format (207) 555-5555

Home Phone

Work Phone

Emergency Contact #1

First Name

Last Name

Relationship to JC

Preferred Phone

Cell Phone

Home Phone

Work Phone

Emergency Contact #2

First Name

Last Name

Relationship to JC

Preferred Phone

Cell Phone

Home Phone

Work Phone

Page 3 of 3 - Parent/Guardian

Thank you for supporting your child by providing us with the following health history information. We are required by the State of Maine to have the following information on file for all of our JC program participants.

Medical and Behavioral Information

If we find we do not have adequate resources to support your Junior Counselor, we reserve the right to cancel their enrollment in our Farm Camp Programs. If you have questions or concerns regarding your child's ability to participate in our programs, please contact Molly Cooper, Farm Camp Manager to discuss ahead of time to ensure we are able to meet your needs.

All fields are required. Please enter N/A if not applicable to your child.

Please list all known allergies, reaction(s), and treatment(s) if exposed.

Please list any dietary restrictions (i.e. vegetarian, lactose intolerant, etc.)

Please list any activity restrictions or limitations (i.e. heart conditions, asthma, seizures, etc.)

Please describe any current health conditions requiring medication, treatment, or special restrictions while at our camp programs. If medication is required during the program, please include name of medication and dosage.

Please list any recent or past hospitalizations, surgeries, or major medical treatments.

Please describe any behavioral, social, emotional, or mental health considerations our staff should know about to ensure we have the necessary resources to support your child at camp.

Has your child received the Covid-19 Vaccine?

If your child has received the Covid-19 Vaccination, please upload a photo of their completed vaccine card.

We are required to have a new copy of each child's immunization records on file each year. We are unable to accept photos of these records. If you have a PDF, please upload it here. If not, you may email it to education@wolfesneck.org, fax it to (207) 865-4884, or mail it to Wolfe's Neck Center for Agriculture & the Environment, ATTN: Education, 184 Burnett Road, Freeport, ME 04032.

Parent/Guardian Permissions

I authorize Wolfe's Neck Center education staff to administer preventative health care and treatment. Please select all that apply

Antacid (Tums)Anti-Itch Topical Cream or Ointment (Hydrocortisone/Benadryl Gel)Antibiotic Ointment (Bacitracin/Neosporin)Antiseptic Pain-Relieving Cleansing Spray (Bactine)Acetaminophin (Tylenol)Antihistamine (Oral Benadryl)None - Please do not administer any medication or medical treatments to my child.

I authorize Wolfe’s Neck Center to use my child’s photo or likeness in promotional or informational materials which may be distributed to the general public in print and digital media.

By submitting this form, I am agreeing to the following: My child has permission to participate in all camp activities. I understand that these activities may include certain risks, and I assume these risks on my own behalf and on behalf of my child. I authorize Wolfe’s Neck Center to secure medical or other treatment for my child at my expense if I am unable to be reached in an emergency. In consideration for my child’s participation in camp activities, on my own behalf and on behalf of my child and our heirs, personal representatives, and assigns, I hereby agree not to sue and to waive, release, and discharge Wolfe’s Neck Center and its subsidiaries and affiliates, officers, directors, agents, employees, and volunteers, of and from any and all claims, causes of action, and damages, which arise out of, or are connected in any way, directly or indirectly, with my child’s participation in the Wolfe’s Neck Center Summer Camp program, including, but not limited to, any claims of negligence.

Yes, I understand and agree.

Thank you for your time in completing the Junior Counselor Application!

Attended previously	Campground stay
Career fair	Email
Facebook	Farm visit
Instagram	Flyer from school
Poster	Farm Camp brochure
Word of mouth