Junior Counselor Application Form
To be filled in by all persons age 16 or 17 applying for a position of as a junior counselor at CISV Jacksonville's local and international camps, particularly FACES of Jacksonville from June 19 to July 1.
Personal Information
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
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District of Columbia
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Rhode Island
South Carolina
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Vermont
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State
Zip Code
Country of Residence
E-mail
*
Applicant's Mobile Phone Number
*
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Area Code
Phone Number
Date of Birth of Applicant
*
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Month
-
Day
Year
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Gender Identity
Female
Male
Non-binary
How do you self-identify?
Asian
Black/African American
Hispanic or Latino
Native American/Alaskan/Hawaiian or Pacific Islander
White
Multiracial
Biracial
A racial/ethnic category not listed
Name of School you attend
Grade in School
Describe health restrictions and their effects on your daily life. Include food allergies, environmental allergies, chronic illnesses, mental & physical health restrictions, dietary restrictions, and simliar issues that affect your participation.
Are you vaccinated against COVID-19?
Yes
No
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List of foreign languages spoken and ability (fluent, good, or fair).
In the CISV program, you will need to assist and or assume responsibility for some activities such as music, arts and crafts, games, sports, dance, discussion and swimming. Please list your interests and skills, which could be helpful at the program:
Do you have certification in lifesaving
Yes
No
Do you have certification in first aid?
Yes
No
Please describe your experience working with people in a leadership role and as part of a team:
Please describe your CISV or other experience with children/youth (of similar age to the specific program participants):
Please describe other experience in CISV, with other intercultural organisations or with other cultures:
Why do you want to be a Junior Counselor?
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Reference Information
Two references are required. Please share the CISV Reference Form to your References listed below and ask them to complete the online form.
Name of Reference #1
First Name
Last Name
Reference #1 Phone Number
-
Area Code
Phone Number
Reference #1 Email
example@example.com
Name of Reference #2
First Name
Last Name
Reference #2 Phone Number
-
Area Code
Phone Number
Reference #2 Email
example@example.com
Training Acknowledgment
Applicant -- Please certify that: I will participate in all CISV Leadership Training Sessions required by CISV. I will abide by and uphold CISV Guidelines on Behaviour and Cultural Sensitivity (Info File R-7) and will put the delegates’ interests and welfare above my own while attending the program. I understand that before serving in a staff/leadership position, I must be a member of CISV. I have no criminal convictions or history of mental illness, emotional counselling, violent behavior, child abuse, drug/alcohol abuse, prejudice etc that would disqualify me from participation in CISV’s international, cross-cultural and peace education programs. I agree to a police record check if required by CISV. I consent to the personal data in this Application Form being used by CISV to process this application and agree that it may be shared with other people involved in organizing the programs, wherever they may be hosted. All the information on this application is correct and accurate.
Yes.
No.
EXPLANATION FOR JUNIOR COUNSELOR APPLICATION FORM
Please see the relevant Program Guide and CISV International policies on selection of persons with Program responsibility Info File R-05 Guidelines on Discrimination, Selection & Behavior.
Data
The personal data provided in this form is confidential and will be kept and eventually destroyed according to the laws of the State of Florida. JCs must be members of CISV Jacksonville or join once they are selected, prior to the Program.
Age Requirements
JCs for FACES must be no younger than 16 years old on June 1, 2022 and no older than 18 on August 31, 2022. All junior counselors must receive appropriate orientation and leadership training as specified in CISV International policies and guides.
References
All Junior Counselors must submit 2 references using the staff/leader reference form.
Signature of Junior Counselor applicant
Date of Signature of CISV Member
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Month
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Day
Year
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