22 Junior 4-H Camp Teen and Counselor-in-Training (CIT) Application
Please complete all fields in this application.  Do not leave questions blank.  Indicate "Not Applicable" where appropriate.  If you have questions about the application process, please contact your 4-H Extension Agent.
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Please note:
If you need accomodations or assistance with completing the application, please notify your local 4-H Extension Agent.

Last Name *
First Name *
Preferred Name (how you prefer to be addressed) *
Position for which you are applying *
County for which you are applying *
Address, Street or PO Box *
Address, Continued
Address, City *
Address, State *
Address, Zip Code *
Home Phone Number, include area code *
Cell Phone Number, include area code *
Email Address *
Age *
Birth Date *
MM
/
DD
/
YYYY
Parent or Guardian Name *
Gender (this is for lodging purposes) *
School you attend *
Please give a brief description of your general experiences in 4-H.  This could include club membership, school programs, participation in 4-H camp as a camper, etc.  If none, indicate "Not applicable". *
Please describe any experiences you have had working with children specifically (jobs, babysitting, camps, etc.).  If none, indicate "Not applicable". *
Please indicate why you would like to be a Teen Counselor or CIT.  Describe the qualities that characterize you and would make you a good teen leader for camp. *
Have you ever been convicted of a crime? *
Have you ever been suspended from school? *
If you answered yes to being convicted of a crime or suspended from school, please describe here. If you answered no, just indicate "Not applicable". *
Reference Names (3 required)
In the next questions, please provide the name and other requested information for references.  Selection of references should be adult teachers, school administrators, youth leaders, church leaders, coaches, etc.  These should not be family members or friends.  Important - please provide an email address for each reference.  We will be sending them a reference form that they can complete electronically.
Name of reference 1 *
How does reference 1 know you; your relationship to this reference? *
Phone number for reference 1 *
Email address for reference 1 *
Name of reference 2 *
How does reference 2 know you; your relationship to this reference? *
Phone number for reference 2 *
Email address for reference 2 *
Name of reference 3 *
How does reference 3 know you; your relationship to this reference? *
Phone number for reference 3 *
Email address for reference 3 *
Teen Counselors can teach classes (must be a Teen Counselor).  If you are interested in teaching a class, please indicate the name of the class, and a short description of the class, here.
During camp, Teen Counselors and CITs assist with classes.  Which types of classes do you prefer for this role?  If you are unable to assist with a class (allergies to animals, limited swimming skills, etc.), please indicate that here as well. *
Please indicate if you would like to be considered for one of the following leadership positions.  Check all that apply.
Please describe your leadership skills and abilities as it relates to your interest in one of the above leadership positions.  Why should you be selected for an Eagle, Big, or Little position?
Roommate or Camper Supervision Preference: CITs can list a roommate preference here.  Teen Counselors can list a preference for camper supervision.  List no more than 2 individuals.  If no preference, indicate no preference.
Tee Shirt Size *
Please check tee-shirt colors needed.  New Teen Counselors and CITs will need all colors.  Check all that apply. *
Required
Junior 4-H Camp Teen Counselor/CIT Agreement/Consent I have read and understand the  4-H Camp Teen Counselor or CIT job description. I understand that all teen applicants must successfully complete a screening, selection, and training process before being allowed to attend 4-H Camp as a Teen Counselor. This process includes: (a) submission of a completed application or resume, (b) reference checks, (c) participation in a face-to-face interview, and (d) completion of all required content training. If selected as a 4-H Camp Teen Counselor, I will uphold the camp rules and procedures and abide by the 4-H Code-of-Conduct during the entire camp week. I will conduct myself as a responsible young adult. I hereby certify that all of the entries on my application or resume are true and complete. I understand that any falsification of information herein constitutes cause for dismissal. I also understand that records and criminal background or reference checks may be conducted on me at any time during the application process or during volunteer service to Virginia Cooperative Extension.  I understand that Virginia Cooperative Extension programs and employment are open to all, regardless of race, color, religion, sex, age, veteran status, national origin, disability, or political affiliation. Virginia Cooperative Extension is an equal opportunity employer.  Please type your name in the space below indicating that you have read and agree to the statements in this application agreement.
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