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Name* Email*
Date of Birth Age as of July 1
Home Address
Town State
Zip Phone*
Present School School term as of September 1
Name, age & sex of any children who will be attending our summer program
Please check the activities you can lead:
Dramatics Wrestling Fine Arts
Newspaper Song Leader Tennis
Paper Crafts Woodcraft Magic
Gymnastics Sewing Cooking
Leather Crafts Swim String art
Baseball Aerobics Golf
Indian lore Basketball Puppetry
Ceramics Nature Soccer
Science Hockey Rock Climbing
Dance Lacrosse Volleyball
Cheerleading Other:
What activities do you feel best at?
Do you play an instrument? Which one?
Yes   No 
Can you read music? Can you teach?
Yes   No  Yes   No 
Age group preferred:
 First   Second   Third 
Ages 3-5
Ages 6-9
Ages 10-12
Ages 13-14
Swimming ability Certifications
Poor   Average   Good  Nassau   WSI 
Have you ever been convicted of a felony (we will check)?*
No   Yes  If yes, explain:
Have you ever been charged with a crime involving children?*
No   Yes 
Please be aware that Merrick Woods does a criminal background check on all employees over the age of 18. Staff members are also subject to pre-employment and random drug testing.
Reference #1
Name Place
Address Phone
Reference #2
Name Place
Address Phone
Do you drive?
No   Yes 
Would you drive a Merrick Woods owned mini-bus?
No   Yes 
Do you need transportation?
No   Yes 
Please write anything you feel might encourage a favorable consideration of your application: