Nurse Application
All applicants must have a license that is valid in New Hampshire and/or a license that is transferrable.
Name:
*
First Name
Last Name
Preferred Pronouns:
Email Address:
*
example@example.com
Phone Number:
*
Please enter a valid phone number.
What weeks will you be available?
*
Adventure Camp (July 6th - 12th)
Youth Camp 1 (July 13th - July 19th)
Youth Camp 2 (July 20th - 26th)
Driver's License # (if applicable)
Driver's License State (if applicable)
Driver's License Expiration Date (if applicable)
Picture of Driver's License (if applicable)
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Church Affiliation
This may not be applicable to all applicants. Please skip this section if you are not affiliated with a church.
Name of Home Church:
Denomination of Home Church
Church Email:
example@example.com
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Work Experience
Employer
*
Dates Employed
*
Job Title
*
Supervisor
*
Phone
*
Complete Address
*
Do you have more work experience?
Please Select
Yes
No
Employer
Dates Employed
Job Title
Email
Supervisor
Phone
Email
Complete Address
Certifications and Education
High School, Degree, and Year of Graduation
College/University
Degree, Year
Any additional education you wish to describe?
What kind of nursing license do you hold?
Please upload an image or pdf of your license.
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Questions and Background Information
Describe your previous experience providing First Aid for large groups of people and accommodating different medical needs.
*
What experience do you have working with children?
*
Explain your experience organizing the administration of medications. Explain how that might transfer to working at a camp where there are numerous different medications that need to be administered to children at different times of the day.
*
Have you ever been convicted or charged with any crime relating in any manner to children and/or your conduct with them?
Yes
No
Have you ever been judged liable for civil penalties or damages involving sexual or physical abuse of children?
Yes
No
Are you now or have you ever been subject to any court order involving sexual or physical abuse of a minor, including, but not limited to a domestic order or protection?
Yes
No
References
Please provide three references who can speak to your ability to fulfill the responsibilities of a staff member.
Reference 1 Name:
*
First Name
Last Name
Reference 1 Relationship to Applicant:
*
Reference 1 Email Address:
*
example@example.com
Reference 1 Phone Number:
*
Please enter a valid phone number.
Reference 2 Name:
*
First Name
Last Name
Reference 2 Relationship to Applicant:
*
Reference 2 Email Address:
*
example@example.com
Reference 2 Phone Number:
*
Please enter a valid phone number.
Reference 3 Name:
*
First Name
Last Name
Reference 3 Relationship to Applicant:
*
Reference 3 Email Address:
*
example@example.com
Reference 3 Phone Number:
*
Please enter a valid phone number.
Submit
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