Name *

First Name

Last Name

Phone *

(###)

###

####

When are you available this summer? *

Please check all that apply

All Summer: June 27 - August 17

Training: June 27-28

Session 1: July 1-5

Session 2: July 8-19

Session 3: July 22 - August 2

Session 4: August 5-16

Clean-Up: August 17

Position Applying For *

Counselor

CIT

Other

Your Age *

13

14

15

16

17 years or older

Education Level *

Current Middle School Student

Current High School Student

High School Graduate

Current College Student

College Graduate

Graduate Student

Other

Please rate your abilities in the following areas. *

I am excellent working with children.

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I am a skilled artist.

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I am a skilled builder.

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Reference #1 Name *

First Name

Last Name

Reference #1 Tel *

(###)

###

####

I have informed this person that I have listed them as a reference. *

True

False

Reference #2 Name *

First Name

Last Name

Reference #2 Tel *

(###)

###

####

I have informed this person that I have listed them as a reference. *

True

False

Media Release *

By checking this box, I hereby give Hudson Lab School permission to use any photographs or other forms of media that I have uploaded for any internal, informational, or publicity purposes. I release Hudson Lab School from any and all liabilities arising from the use of my name, photograph or video in items including, but not limited to, news releases, brochures, and websites and I waive the right to inspect/approve the finished items.