COUNSELOR IN TRAINING APPLICATION FORM
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
In the fall of 2025, which grade will you be in?
*
Grade 6
Grade 7
Grade 8
Freshman
Sophomore
Junior
Senior
Graduating High School
Age (minimum Age is 13 yrs) Can make exception for talented middle schoolers.
*
Which school do you attend?
*
PALY - Palo Alto High
Gunn - Gunn High
Other
Why are you interested in this opportunity?
*
Please Select
For a stipend. I have prior work/camp experience and so can find other paid work, but love playing with LEGO.
I am fine with no stipend. I have no prior experience. I am interested in work experience.
Parent/Guardian Information
Name
*
First Name
Last Name
Address (If different from above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent Email
*
example@example.com
Parent Phone Number
*
Please describe why you are interested in becoming a counselor-in-training for BrainVyne Camps?
*
Please describe your interest / experience with computers, technology and / or LEGO®:
*
Would you be interested in working in our office located at 4000 Middlefield Rd Palo Alto CA 94303 on Marketing and Operations Projects?
*
Availability
Please check the box below for the cities in which you want to volunteer as a Counselor-In-Training. Be sure to select N/A for the areas you are not interested in.
*
Burlingame
Foster City
Los Altos
Menlo Park
Mountain View
Palo Alto
Redwood City
San Carlos
San Mateo
N/A
Peninsula
Please check the box below for the cities in which you want to volunteer as a Counselor-In-Training.
*
Cupertino
Gilroy
Milpitas
Morgan Hill
Santa Clara
San Jose/Evergreen
San Jose/Los Gatos
Sunnyvale
N/A
South Bay
Please check the box below for the cities in which you want to volunteer as a Counselor-In-Training.
*
Berkeley
Concord / Walnut Creek
Dublin
Fremont
Livermore
Pleasanton
Union City
N/A
East Bay
Check "Yes" for weeks you are available to work and "No" for weeks you are unavailable.
*
Yes
No
M-F 4/31 - 4/04
M-F 4/07 - 4/11
M-F 4/14 - 4/18
Check "Yes" for weeks you are available to work and "No" for weeks you are unavailable. You must commit to a minimum of two weeks. * No camp on July 4th.
*
Yes
No
M-F 6/02- 6/06
M-F 6/09 - 6/13
M-F 6/16 - 6/20
M-F 6/23 - 6/27
M-F 6/30 - 7/04*
M-F 7/07 - 7/11
M-F 7/14- 7/18
M-F 7/21- 7/25
M-F 07/28 - 8/01
M-F 8/04 - 8/08
M-F 8/11 - 8/15
M-F 8/18 - 8/22
M-F 8/25 - 8/39
If hired you must attend mandatory training (paid) on the following dates. Please reply with whether these dates work for you or not.
*
Yes
No
N/A
Spring Camp Training Saturday March 29
Summer Camp Training Saturday June 07 (All Day)
Summer Camp Training II Sunday June 15 (All Day)
If you are not available for any of the training dates above, please specify your availability below, else please write n/a :
*
What hours are you available to work? Select all options that fit your schedule.
*
Yes
No
Camp Hours Full Day 8:00am to 3:00pm
Camp Hours Half Day 8:00am to 12:00pm
Afternoon 1:00 PM - 5:30 PM
List any prior C.I.T Experience
Name of Employer
From (MM/YYYY)
To (MM/YYYY)
Position
Anything else you would like to share?
References
Please list the names, relationship / organization and phone numbers of two (2) adults, not related to you, whom you have known at least two (2) years. (e.g. teachers, coaches, volunteer project managers etc...) If you do not know email address, write in donotknow@email.com.
*
Name
Relationship/ Organization
Phone
Email Address
1
2
Medical
Do you have any medical conditions or allergies?
*
No
Other
Disclosure
Are you legally authorized to work in the United States?
*
No
Yes
Counselor-In-Training Agreements
CIT Agreement “I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if accepted as a CIT, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed above to give us any and all pertinent information they may have, personal or otherwise and release all parties from all liability for any damage that may result from furnishing same to us. I understand and agree that, if accepted as a CIT, my volunteer position may be terminated at any time without prior notice.” Please type in your name below in lieu of a signature.
*
Your Signature
Parent Agreement “I agree to the statement above and as parent or legal guardian of the above-named individual, I hereby absolve BrainVyne LLC, their employees, officers and activity instructors, as well as the school site and district, from all liability, which may arise as a result of the above individual’s participation in the Counselor-in-Training program. I understand that the Summer classes and activities may involve accidental injury and hereby voluntarily assume such risks.” Please type in your name below in lieu of a signature
*
Your Signature
Photography Authorization I consent to BrainVyne's use of any photographs or video-recordings that are taken of my child while participating in this volunteer program for use in BrainVyne's website, brochures and program materials that are distributed both as printed document and on the internet. No payment will be made for use of these photographs and / or videos. Your child’s name will never be used in connection with these images.
*
No
Yes
If you authorized use of your child's pictures & videos, please type in first and last name below in lieu of a signature
Your Signature
Date
*
-
Month
-
Day
Year
Date
OPTIONAL: Please submit a copy of your resume.
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