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Personal Information

First Name: *
Midde Name:
Last Name: *
Date of Birth: *
Social Security No:

Home Address

Street: *
Street (Line 2):
City: *
State: *
Zip: *
Telephone: *
Cell Phone:
Email: *
Dates Applicable:

School Address

Street:
Street (Line 2):
City:
State:
Zip:
Telephone:
Email:
Dates Applicable:

Education

College/University:
Dates of Attendance:
Degree Granted:
 
College/University:
Dates of Attendance:
Degree Granted:
 
College/University:
Dates of Attendance:
Degree Granted:
 

Background

How did you first become aware of American Trails West?

Have you been hospitalized during the last three years?
Yes No

If so, why and when?

Do you have any emotional or physical condition which might impair your ability to participate fully in all activities such as hiking, biking, swimming, etc.?
Yes No

If so, please explain:

Do you have a current driver's license?
Yes No

State:
I.D. No:

How long have you been driving?

Do you have any experience driving a van or a truck?

List any moving violations during the last three years:

Work Experience

Have you worked in an organized camp setting as a Counselor, Waiter, or Group Leader? *
Yes No

If yes, please list the name(s) of the Camp(s), position(s) held, and year(s) worked:

Do you have any camping experience, counseling experience, or experience working with young people other than in an organized camp setting? *
Yes No

If yes, please describe:

In a short statement summarize your motivation for traveling with AMERICAN TRAILS WEST: *

What specific contributions do you think you can make to the success of an AMERICAN TRAILS WEST Tour? *

Are you certified in either of the following areas? If yes, please give dates of expiration:

CPR:
First Aid:

References

Please list three professional references who can comment on your character, your sense of responsibility, and your ability to work with teenagers. Professional references may include employers, teachers, camp directors, etc. (Do not include relatives.)

Name:
Position:
Street Address:
Street Address (Line 2):
City:
State:
Zip:
Telephone:
Email:
 
Name:
Position:
Street Address:
Street Address (Line 2):
City:
State:
Zip:
Telephone:
Email:
 
Name:
Position:
Street Address:
Street Address (Line 2):
City:
State:
Zip:
Telephone:
Email:
 
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ATW TEEN TOURS • American Trails West • 516.487.2800 • Fax: 516.487.2855 •

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