Camp USA/Guy Healy and UW-Whitewater Summer Internship in Japan Application

Part 1: Applicant Information

1. Full Name:
2. Birthdate (MM/DD/YYYY):
3. Check one: Male Female
4. Year in School: Freshman Sophomore Junior Senior
5. Major:
6. Minor:
7. Approximate Overall GPA:
8. Address:
9. E-mail:
10. Citizenship:
11. 1. Have you taken/taking now any college-level Japanese (Japanese 101 or higher)? Yes No
12. 2. Have you taken/taking now Cross-Cultural Communication (Speech 424)? Yes No
13. 3. Have you taken/taking now an Anthropology/Geography/History/ Political Science/Sociology on Japan or East Asia? Yes No
14. 4. Have you ever been convicted of a felony?  Yes No
15. If YES, explain:
    
16. 5. Are you in good physical and mental health? Yes No
17. If NO, explain:
    
18. 6. Can you be available from June 25 to August 29? Yes No
19. 7. Have you ever traveled outside the United States? Yes No
20. If YES, explain:
    
21. 8. Do you have any dietary restrictions? Yes No
22. If YES, what:
    
23. 9. Do you have a current passport? Yes No
24. If YES, what country:
    

25. Part 2: References Provide 2 references (work or school) [Excluding Ms. Kato & Dr. Neuman]

    Reference 1

26. Name:
27. Business/School:
28. Address:
29. Phone:
30. E-mail:
31. Relationship:

32. Reference 2

33. Name:
34. Business/School:
35. Address:
36. Phone:
37. E-mail:
38. Relationship:

39. Part 3: Questions

40. 1. Why are you interested in this program?
41. 2. What work or volunteer experience that is related to being a camp counselor for children/teens?
42. 3. Why do you think you would be a good counselor?
43. 4. How would this program help your personal or career goals?
44. 5. What are your hobbies and interests?
45. 6. Any further comments to support your application?

46. Part 4: Agreement - Camp USA Counselors Agreement (please read, and print for your records)

    Enter your full name, UWW student id number, and date only if you agree with the statement below

    I have read the entire counselor agreement form and agree to all 13 of its stipulations:

47. Name:
48. UWW ID:
49. Date: