Remember to TAB between fields, do not press ENTER!
First & Last Name Gender M F Age Birthdate
Home Address
City/Town Prov/State Postal/Zip CodeTelephone
Email address (REQUIRED TO RECEIVE REPLY)
Children in Family:
Name Age Gender M F Hockey Player? Y N
Name Age Gender M F Hockey Player? Y N
Name Age Gender M F Hockey Player? Y N
Name Age Gender M F Hockey Player? Y N
Social Insurance Number: Ontario Health Card Number:
Postion Applying for:
References (outside family, work related)
1) Name Home Telephone Work Telephone
Relationship to You Email
2) Name Home Telephone Work Telephone
Relationship to You Email
Note: Email address for references are required. References will be contacted via email.
Most Recent Employment (last two years)
Current Employer From toTelephone
Type of Work Supervisor
Previous Employer From toTelephone
Type of Work Supervisor
Please explain your camp experience as a staff member (including name of camps worked)
Please provide us with a brief history of your health care work experience (not camp related):
Under the signed medical directives of a doctor, would you feel comfortable administering medications such as
Acetaminophen, Ibuprofen, Gravol, Kaopectate, cough syrup, Epi Pen, etc in our camp environment? Yes No
Please identify all volunteer work (health care, coaching, mentoring, teaching, etc.)
Do you have any additional experience or qualifications that would benefit your work in our camp community?
Are you currenlty registered as a Physician in the Ontario College of Physicians? Yes No For how many years?
Are you currenlty registered as a Registered Nurse in the Ontario College of Nurses? Yes No For how many years?
Ontario Registration Number:
Please choose the weeks that you prefer: First Choice
Second Choice
All successful staff candidates will be required to submit a criminal background report with their contract.
Are you willing to have a police check done and sent to us in the event that you are hired? Yes No
