2021 NOVA 4-H Summer Staff Application

2021 NOVA 4-H Summer Staff Application

Thank you for your interest in joining Team NOVA at the Northern Virginia 4-H Educational & Conference Center! It is because of YOU that over 2,000 youth will have an amazing experience at camp this summer.

Personal Information
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Permanent (Home) Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Current (School) Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Phone *
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Email Address *
example@example.com
Position Sought: (use position titles that are listed later in this application) *

Education
Have you completed High School? *

Yes No
If not, do you have a GED?

Yes No
Please list any college experience you have:
College or University Name:
Major or Area of Study:
Type of Degree:
Graduation Date:
(or expected date)
College or University Name:
Major or Area of Study:
Type of Degree:
Graduation Date:
(or expected date)

Work Experience:

Describe all paid, military, and applicable volunteer experience. Highlight your knowledge, skills, and abilities that best demonstrate your qualifications for this position.
1). Employer Name: *
Employer Phone: *
Please enter a valid phone number.
Employer Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Duties: *
May we contact this employer? *

Yes No
2). Employer Name:
Employer Phone:
Please enter a valid phone number.
Employer Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
May we contact this employer?

Yes No
3). Employer Name:
Employer Phone:
Please enter a valid phone number.
Employer Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
May we contact this employer?

Yes No

License & Certifications

Include driver's license and other pertinent certifications (first aid, CPR, lifeguard, etc.)
Include: Certification Name, License or Reference Number, Expiration Date, and the Licensing Board:
(ex. CPR, #123456, exp: 8/2021, American Red Cross)
Include: Certification Name, License or Reference Number, Expiration Date, and the Licensing Board:
(ex. CPR, #123456, exp: 8/2021, American Red Cross)
Include: Certification Name, License or Reference Number, Expiration Date, and the Licensing Board:
(ex. CPR, #123456, exp: 8/2021, American Red Cross)
Include: Certification Name, License or Reference Number, Expiration Date, and the Licensing Board:
(ex. CPR, #123456, exp: 8/2021, American Red Cross)

Miscellaneous
For purposes of compliance with The Immigration Reform and Control Act, are you legally eligible for employment in the United States? *

Yes No
For purposes of compliance with Section 2.2-2903 of the code of Virginia, are you a veteran who received an honorable discharge and has (i) provided more than 180 consecutive days of full-time active-duty in the armed forces of the United States or reserve components thereof, including the National Guard, or (ii) has a service connected disability rating fixed by the United States Veteran Affairs? *

Yes No
What date will you be available to start work? *

Month Day Year
Date
Are you interested in becoming a Lifeguard? *

Yes No Already certified
Do you have reliable transportation? *

Yes No
T-Shirt Size *

References

Please list three references other than family members who can attest to your personality, character, and professional qualities. IF YOU ARE A NEW STAFF MEMBER YOU MUST ALSO COMPLETE REFERENCE FORMS (see below for more details).
1). Reference Name: *
Reference Phone: *
Reference Email: *
2). Reference Name: *
Reference Phone: *
Reference Email: *
3). Reference Name: *
Reference Phone: *
Reference Email: *
New Staff: In order to complete the application process, you will need to have three references who have knowledge of your personality, character, and professional qualifications complete an online reference form.

It will be your responsibility to contact your references and provide them with the link to our online reference form https://form.jotform.com/203024081167142

Applications will NOT be considered and candidates will NOT be contacted for an interview until all three completed reference forms are received. Be sure to give your references plenty of time to complete this form and follow up with them to verify the completion. Remember that the priority application deadline is December 1st.

Camp Skills

Please list your knowledge and skills in the following areas using the following values: 1 = no interest, 2 = no experience, 3 = some knowledge/interest, 4 = can assist with activity, 5 = can instruct/lead activity
Campfire Programs *
Challenge Course/Teambuilding *
Creative Arts/Fine Arts *
Forestry/Nature Education *
Group Games *
Homesteading *
Leadership Development *
Leathercraft *
Medical Training *
Outdoor Living Skills/Cooking *
Paddling Sports *
Programming *
Shooting Sports *
Song Leadership *
Supervisory Skills *
Swimming *
Yoga/Restorative Fitness *
Recreational Sports *

Desired Position
Identify the positions of highest interest and share your experience in each area. If you have questions about what a position entails please email tennantk@vt.edu.
Position Title *
Preference Ranking (1-4 with 1 holding the highest preference) *
# of years participating in this activity *
If none enter 0
# of years leading this activity *
If none enter 0
List any certifications you currently have or have had for this activity:
Position Title *
Preference Ranking (1-4 with 1 holding the highest preference) *
# of years participating in this activity *
If none enter 0
# of years leading this activity *
If none enter 0
List any certifications you currently have or have had for this activity:
Position Title *
Preference Ranking (1-4 with 1 holding the highest preference) *
# of years participating in this activity *
If none enter 0
# of years leading this activity *
If none enter 0
List any certifications you currently have or have had for this activity:
Position Title *
Preference Ranking (1-4 with 1 holding the highest preference) *
# of years participating in this activity *
If none enter 0
List any certifications you currently have or have had for this activity:
# of years leading this activity *
If none enter 0

Your Soapbox...
Please tell us why you are interested in working at camp? *
What qualities or skills do you possess that would make you the best candidate for a camp staff position? *
What contributions would you bring to the camp staff? *

Employment Dates
As a full-time seasonal employee of the 4-H Center, you are expected to be on time and present for all of the camp activities and trainings events listed below. A typical week has a Sunday morning start time of 10am and Thursday evening end time of 6pm.

If you are unable to be present for the dates below, please strongly consider your ability to committ to working at the 4-H center this summer.

Review the list of TENTATIVE dates below and then check the appropriate choice below the list of dates.
- February 26-28: TALT (unpaid)
- Mid May (TBD): State Staff Training (unpaid)
- Late May/Early June (TBD): Center Staff Training
- June 6-10: Jr. Camp
- June 13-17: Jr. Camp
- June 20-24: Jr. Camp
- June 27-July 1: Jr. Camp
- July 2nd: 4th of July Celebration
- July 4-8: Jr. Camp
- July 9-11: Specialty Camp Weekend
- July 11-15: Jr. Camp
- July 18-22: Jr. Camp
- July 25-29: Camp Smile & Specialty Camp
- Aug. 1-6: TBD/Specialty Camp
What is your summer availability? *

I am able to attend all trainings and camp sessions I anticipate having a conflict with one or more of the above commitments

Certification
I hereby certify that all entries in this application are true and complete, and I agree and understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part to any employment in the service of the 4-H Educational Center. I understand that all information on this application is subject to verification and I consent to criminal history background checks. I also consent to references and former employers and educational institutions listed being contacted regarding this application. I further authorize the 4-H Educational Center to rely upon the use, as it seems fit, any information received from contacts. Information contained on this application may be disseminated to other agencies, nongovernmental organizations or systems on a need-to-know basis for good cause shown as determined by the center head or designee.
Signature: *

Clear
Today's Date: *

Month Day Year
Date
Virginia Cooperative Extension programs and employment are open to all, regardless of age, color, disability, gender, gender identity, gender expression, national origin, political affiliation, race, religion, sexual orientation, genetic information, veteran status, or any other basis protected by law. An equal opportunity/affirmative action employer.

Individuals with disabilities desiring accommodations in the application process should notify Northern Virginia 4-H Educational Center at 434-248-5444 by the application deadline.
*TDD number is (800) 828-1120.
Should be Empty:

2021 NOVA 4-H Summer Staff Application

Personal Information

Education

Work Experience:

License & Certifications

Miscellaneous

References

Camp Skills

Desired Position

Your Soapbox...

Employment Dates

Certification