Stem Camp_Staff Info And Availability Form

Name of Applicant

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

Date

Date Today

Date

Choose Your Role:

Choose Your Senior Camp Availability:

Tues, 7/16

Choose Your Teen Camp Availability:

Wed, 7/17Thurs, 7/18

Choose Your Child Camp Availability:

What Is Your T-Shirt Size?

Are You CPR & First Aid Certified?

YesNo

Are You Currently Employed At A School, Child Care Center, Or Other Youth Program?

YesNo

If Yes, Please List The Name Of The Organization And The Nature Of Your Work There.

If The Nature Of Your Current Work Is Not Related To Education or Youth Development, Please Describe.

Are You Currently A High School Student?

YesNo

If Yes, Please List The Name Of The School And The Grade You Will Be Entering In The 24/25 School Year.

Please Note Any Relevant STEAM, Educational, Or Youth Development Experience.

Name

First NameLast Name

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

I hereby declare that the information I have provided above is true and correct to the best of my knowledge. I understand that any misleading or false information I provide that was substantial to the consideration of my application shall cause the termination of my participation in the program.

I understand that working as a CITS STEM Camp Staff Member is not to be construed as an employment agreement in any way and that I will be working as an independent contractor.

I authorize Computer Island Technology Services LLC to request and review my Criminal Justice Information System (CJIS) Background Check and my Child Protective Services (CPS) Background Check.

I understand that I have a right to challenge the accuracy of the information in my FBI criminal history record and that the procedures for obtaining a change, correction, or update of my FBI criminal history record are set forth at 28 CFR 16.34 and that information regarding this process may be found at https://www.fbi.gov/services/cjis/identity-history-summary-checks and https://www.edo.cjis.gov.

To Sign As Applicant Please Type In Your Name Below:

Date

Name of Parent/Guardian If A High School Student

First NameLast Name

Parent/Guardian's Phone Number

Please enter a valid phone number.

Parent/Guardian's Email Address

example@example.com

To Sign As Parent/Guardian Please Type In Your Name Below:

Date

Stem Camp Staff Info & Availability Form

Role Interested In & Availibilty

Contact In Case of Emergency

Acknowledgment