2018 Junior Counselor Application Form

Page 1 of 3 - JC Applicant

Thanks for your interest in serving as a JC at Wolfe's Neck Center! JC applicants should fill out pages 1 and 2, while your parent or guardian should fill out page 3.

Please note: Complete applications received by April 15th will receive priority consideration.

We look forward to receiving your application!

Junior Counselor's Information

Your First Name

Your Last Name

Nickname (if any)

Gender

Date of Birth

Grade Entering in Fall 2018

Name of School

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

Parent/Guardian Contact Info

Parent/Guardian First Name

Parent/Guardian Last Name

Relationship to JC

Billing Street

Billing City

Billing State

Billing 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 in spending part of their summer at Wolfe's Neck Center! 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

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

Please list all known allergies and treatment if exposed

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 past medical treatments

Any special dietary needs (i.e. Vegetarian, Lactose Intolerant, etc.)

Behavioral or other information education staff should know to ensure your child has a positive experience

I authorize Wolfe's Neck Center education staff to administer preventative health care and treatment such as sunscreen and/or bug spray

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 the 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, 184 Burnett Road, Freeport, ME 04032.

Parent Permissions

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.

Do you have any additional comments?

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