Senior Camp Counselor Job Description Page 3
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5Jr. Marine Biologist 2015
CIT Application
Please fill out this application packet completely and return to Hannah Campbell at
no later than Friday, May 1, 2015.
Applicant Information:
Applicant’s Name:_________________________________________ Age:______
Birthdate:_________
Local Address:____________________________________________ City:_______________
Zip:____________
Home Phone:______________________________
Cell Phone:_________________________________
Parent/Guardian Name(s):__________________________________________________________________
Parent/Guardian Daytime Phone:_________________________ Evening Phone:_______________________
Mailing/Home Address (if different than above):_________________________________________________
Emergency Contact Information:
Name:______________________________________________
Relationship:_________________________
Phone:______________________________________________
Alternate Phone:______________________
Sessions:
(Indicate all sessions you’d like to be considered for. We require a minimum of three weeks
Training: May 25 (Mandatory) _X_
Session 6: July 13-17
___
Session 1: June 8-12
___
Session 7: July 20-24
___
Session 2: June 15-19
___
Session 8: July 27- 31
___
Session 3: June 22-26
___
Session 9: August 3-7
___
Session 4: June 29-July 3
___
Session 10: August 10-14
___
Session 5: July 6-10
___
Circle T-Shirt Size (indicate quantity – 2 shirts are included; extras are $10):
Youth XL __
Adult S __
Adult M __
Adult L __
Adult XL __
Other Size: ____
Release of Liability:
I understand the Marinelife Center’s Junior Marine Biologist (JMB) Program is designed to provide students with
hands-on experience in the field of conservation. I understand a large part of the experience will involve
interacting with all aspects of nature, including live sea turtles. I release the Marinelife Center, its employees,
volunteers and affiliates from any and all liability claim, cost or expense arising directly from any such activity in
which my child may participate during the JMB Program. I hereby give permission for my above named child to
participate in all aspects of the JMB Program as referenced on the JMB Medical Release and JMB Agreement. I also
give permission for the Marinelife Center to use my child’s photo in future LMC publications.
_________________________
__________________________
___________
Student signature
Signature of parent / legal guardian
Date
(If applicant is under the age of 18)
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