Camp Councelor Application Form



Return by Wednesday, February 21st to the Waukesha County UW Extension Office

| |

|Name:______________________________________________________________________________ |

|Address:______________________________________________________________________________ |

|City:________________________ |Zip:_________________ |Home Phone:_____________________ |

|Cell Phone:__________________ |Age:________________ |Current Grade:_____________________ |

|Club:_______________________ |Email:__________________________________________________ |

| |

|Parent Email:____________________________________________________________________ |

|ANSWER THE FOLLOWING ABOUT YOUR EXPERIENCE(S) IN 4H AND 4H SUMMER CAMP |

|I have been in 4H for ____years | |

|Check all that apply: | |

| |I have been a 4H camper____ |

| |I have been a 4H Counselor in Training (CIT)____ |

| |I have been a 4H Counselor (CO)____ |

| |I have been a Senior Counselor (Sr. CO)____ |

|OTHER CAMPING EXPERIENCES (List camps attended other than 4H camp) |

|Year |Name of camp |Kind of camp |Length of camp |

| | | | |

| | | | |

| | | | |

| | | | |

|4H is all about the BIG M (Belonging, Independence, Generosity and Mastery). Provide at least 2 examples of how you can support the BIG M as you work with your |

|campers: |

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|_______________________________________________________________________________________________________________________________________________________________________|

|_____________________________________________________________________________________________________________ |

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|___________________________________________________________________________________________ |

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|Why do you want to be a 4-H camp counselor, and what qualities do you have that you can use to enhance the camp experience? |

|_______________________________________________________________________________________________________________________________________________________________________|

|_______________________________________________________________________________________________________________________________________________________________________|

|__________________________________ |

|What experiences have you had as a leader in a camp situation? (Both 4-H and non-4H). |

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|_______________________________________________________________________________________________________________________________________________________________________|

|_____________________________________________________________________________________________________________________________________________________________________ |

|Every year camp has a theme. What theme ideas do you have for camp? How would you apply that theme to the various activities at camp? |

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|_______________________________________________________________________________________________________________________________________________________________________|

|_______________________________________________________________________________________________________ |

EMERGENCY CONTACT:

NAME PHONE NUMBER

NAME__________________________________________ PHONE NUMBER _______________

APPLICANT SIGNATURE DATE

PARENT/GUARDIAN SIGNATURE DATE

RETURN BY Wednesday, February 21, 2019 TO:

Attn: Molly Ellis

Waukesha County UW-Extension

515 W Moreland Blvd Rm AC G22

Waukesha WI 53188

mellis@

262 548-7774 - Fax 262 548-7787 - (Wis Relay) 711

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If you are chosen as Camp Staff, you are expected to attend ALL camp training meetings.

If you are unable to attend a meeting,

please contact Jann Pfaff at

cell: 262-751-3009 or text

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