Date:_________

Personal
1. Full Name: ___________________________________ Soc. Sec #: _______________

The following items are optional: 2. Age: ______ Date of Birth: ___________________ Height: _________ Weight: _________

3a. School Address: _____________________________________________________

City: __________________________ State: ____________ Zip Code: ____________

School Phone Number: _________________

3b. Home Address: __________________________________________________________

City: ________________ State: __________ Zip Code: __________

4a. Home Phone Number: ______________ e-mail: ______________________________

4b. Cell Phone Number: ______________

5. How did you hear of Weissman Teen Tours? ________________________________

6. Do you have any dietary restrictions? (I.e. Vegetarian, lactose intolerance, etc.) Please explain:

_______________________________________________________________________________________________

7. Are you a US citizen? _________

8. Do you smoke cigarettes? __________

9. Do you have any criminal record? _________, or have you ever been arrested? ________

10. Do you have any limitations that would preclude you from 100% participation in our activities? (Please explain)

_______________________________________________________________________________________________

_______________________________________________________________________________________________

11. Have you been hospitalized during the past 3 years? (Please explain)

_______________________________________________________________________________________________

College Information
12. College: _____________________________

Degree: ________ Major: ___________ Grad Date: _________

     Post Grad: _____________________

Degree: ________ Major: ___________ Grad Date: _________

Summer Work Experience
13a. Camp/Company Name: _______________________ Dates Employed: _______________

Position: _______________________ Responsibilities: ____________________________

Address: ________________________________________________________________

City: ______________________ State: ______________ Zip Code: _____________

Phone Number: ___________________ Contact Person: ____________________

13b. Camp/Company Name: _______________________ Dates Employed: _______________

Position: _______________________ Responsibilities: ____________________________

Address: ________________________________________________________________

City: ______________________ State: ______________ Zip Code: _____________

Phone Number: __________________ Contact Person: ____________________

Occupational Experience
14. If Graduated, occupation: ____________________________________ Years _____

15. If a teacher, which levels or subject: ___________________________________________

16. Do you coach any sports? (Not a requirement) _______

If yes, which sports? ________________________________________________________

Related Experiences & Hobbies
17. Do you have any camping experiences? (Not a requirement) _______________________

__________________________________________________________________________

18. Do you have current life saving certification (LGT) __________Exp. Date ____________

Do you have current First Aid & CPR certification ___________ Exp. Date ___________
Note: (You may take this one day course at your local Red Cross once you have been hired for the position)

19. Activities or sports you participate in: _________________________________________________

20. Hobbies and interests:

_______________________________________________________________________________________________

21. Do you have any photography experience? ________ Please explain:

_______________________________________________________________________________________________

22. List any foreign languages you speak fluently ________________________________________

23. Which areas of the United States and/or Europe have you visited?

_______________________________________________________________________________________________

_______________________________________________________________________________________________

24.What experience do you have working with teenagers?

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Personal Statement
25. Why do you want to lead a teen tour this summer and what contributions can you make to Weissman Teen Tours?

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

26. What do you think is the most important thing a teenager should gain from his experience from Weissman Teen Tours?

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

27. Kindly indicate three professional references who can comment on your character, your sense of responsibility, and your ability to work well with teenagers (i.e. employers, camp directors, college professors, school principals, etc. - no friends or relatives).

A) Name/Profession/Relationship: __________________________________________________________________

Address: ________________________________________________________________________________________

City: ________________________ State: ____________ Zip Code: __________

Business Phone: __________________ Home Phone: _________________ e-mail: __________________________

B) Name/Profession/Relationship: __________________________________________________________________

Address: ________________________________________________________________________________________

City: ________________________ State: ____________ Zip Code: __________

Business Phone: __________________ Home Phone: _________________ e-mail: __________________________

C) Name/Profession/Relationship: __________________________________________________________________

Address: ________________________________________________________________________________________

City: ________________________ State: ____________ Zip Code: __________

Business Phone: __________________ Home Phone: _________________ e-mail: __________________________