JUNE 17-21, 2024

Holiday Lake 4-H Educational Center, Appomattox, VA

*** RETURN BY MARCH 4, 2024 ***

TO:	Ellen Powell Virginia Department of Forestry 900 Natural Resources Drive, Suite 800, Charlottesville, VA 22903	PHONE: (434) 987-0475 EMAIL: ellen.powell@dof.virginia.gov FAX: (434) 296-2369
SECTION 1 – Applicant Information
Applicant Name:
Last Name	First Name	M.I.
Agency/School:
Address:
Mailing Address	City	State	Zip Code
Home Phone No.:	Email:
Business Phone No.:	Cell Phone:
How many years have you been a staff member at Holiday Lake Forestry Camp?	First Year
T-shirt Size:	S	M	L	XL	XXL	XXXL
SECTION 2 – Schedule
Camp runs June 17-21. Meals begin with Monday lunch and end with Friday lunch. To help us schedule adequate supervision for the campers, please complete the following schedule information.
I will attend the full week, Mon.-Fri. – Days and Overnight	Check here if arriving Sun. Night
I will attend the full week, Mon.-Fri. – Daytime Only
Check here if you need to miss any days or nights (Ellen will contact you)
SECTION 3 – Exploratory and Beyond the Basics Classes
Please check the exploratory classes you’d be willing to assist with. Special knowledge of the subject can be helpful but is not required, as the instructor will lead. We’ll do our best to accommodate your preferences.
Canoeing	Wildlife Techniques	Archery
Forest Measurements	Primitive Technology	Wilderness Survival
Ropes	Stream Analysis	Fire Equipment & Tactics
We are always open to new exploratory classes. If you have an idea for a new class you can teach, please list it here:
SECTION 4 – Signature
I certify that the information provided is true and complete. I understand that staff are responsible for campers’ safety, well-being and learning, and will honor my commitment to serve as a 2024 staff member. I also recognize my conduct as a staff member has an impact far beyond myself and hereby agree to follow all camp policies, and to be a positive example for campers in matters of teaching, citizenship, sportsmanship, teamwork and friendship.
Applicant Name (print)	Applicant Signature	Date

SECTION 5 – First-Year Applicants Only (Please complete these sections.)
Community, civic/service club or youth organization activities, including prior camp experiences:
Do you hold any medically-related certifications (e.g., first aid, CPR, EMT, nursing degree, etc.)? Please give type and dates:
Other specialized training:
References:	Please list all contact information (name, address, phone and email) for two individuals, other than relatives, who know you well enough to serve as a reference (VDOF coworkers/supervisors are fine):
1)	Name:	Relationship:
Address:
Mailing Address	City	State	Zip Code
Phone No.:	Email:
2)	Name:	Relationship:
Address:
Mailing Address	City	State	Zip Code
Phone No.:	Email:
SECTION 6 – Background
Have you ever been convicted of a law violation, including moving traffic violations, but excluding offenses committed before your 18th birthday, which were adjudicated in Juvenile Court?	Yes	No
If yes, list all and explain: