Name Email Date of Birth Age as of July 1 Home Address Town State Zip Phone Social Security # Present School Overall School Grade Average Present Grade   What have you done over the past summers Summer 2007 Summer 2006   Please check the activities you can lead Dramatics Video Newspaper Tennis Arts & Crafts Gymnastics Cooking Swim Fishing Baseball Golf Basketball Photography Ceramics Pottery Soccer Nature Hockey Rope Course Dance Lacrosse Volleyball Boating Computers Radio Cheerleading Other:     Activities you feel you can specialize in:   Were you a Jeff Lake camper? Yes No   Can you read music? Yes No     Age group preferred:  First   Second   Third  Ages 3-5 Ages 6-9 Ages 10-12 Ages 13-14   Swimming ability Poor Average Good   Certifications ALS WSI   Have you ever been convicted of a felony (we will verify)? Yes No   Have you ever been charged with a crime involving children? Yes No   Please be aware that Jeff Lake Camp does a criminal background check on all employees over the age of 18.   Reference Name Place Address Phone I was recommended by Friends who work at JLC   Please write anything you feel might encourage a favorable consideration of your application: