P. O. Box 12306 Austin, Texas 78711 



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Form 3932

Page / 05-2017





Form 3932

May 2017


Office of Deaf and Hard of Hearing Services

Camp SIGN Application for Counselors  

Complete this application and return it to:

Office of Deaf and Hard of Hearing Services

P.O. Box 12306

Austin, Texas 78711 



If you have questions, contact us at:

Phone: (512) 410-0978

Fax: (512) 407-3299

Email: dhhstraining@hhsc.state.tx.us

Website: hhs.texas.gov/services/disability/deaf-hard-hearing


Position for which you are applying: enter 1 to select first choice and 2 to select second choice.  

   Counselor    Counselor and cabin coordinator    Nurse

   Junior counselor    Counselor and activity leader    Other: Specify:      

Applicant Information  

Last name:

     


First name:

     


Birth date:

     


Age:

     


Enter X to select sex:

   Male    Female

Email address:

     


Address:

     


City:

     


State:

     


ZIP code:

     


Home phone:

(   )      



Pager:

(   )      



Work phone:

(   )      



Cell phone:

(   )      



Enter X to select one from each of the following categories.  

T-shirt
(adult size):

   S

   M

   L

   XL

   XXL

   XXXL

Status of hearing loss:

   Deaf

   Hard of hearing

   Hearing impaired

   Cochlear implant

   Other

Method of communication:

   American Sign Language

   Signed Exact English

   Sign Language

   Oral

   Other (specify):

     


Expressive skills:

   Excellent

   Good

   Fair

   Poor

Receptive skills:

   Excellent

   Good

   Fair

   Poor

Evaluation Criteria  

Qualifications should reflect the job functions of the position for which you are applying.

Each section may be awarded points up to the amount listed.  



Camp Experiences (Possible Points: 15)  

Counselor

[5 pts]


   Yes

   No

If yes, how many years?

   1-3 [2 pts]    4-9 [3 pts]

   10+ [5 pts]

Counselor-in-Training (CIT)

[3 pts]


   Yes

   No

Camper

[2 pts]


   Yes

   No

Communication Skills (Possible Points: 50)  

Check all that apply to your skills. (Excellent = 5 points, Good = 3 points, Fair = 1 point)  

Expressive Skills  

   ASL [5 pts]

   Excellent    Good    Fair

   SEE [3 pts]

   Excellent    Good    Fair

   ORAL [2 pts]

   Excellent    Good    Fair

Receptive Skills  

   ASL [5 pts]

   Excellent    Good    Fair

   SEE [3 pts]

   Excellent    Good    Fair

   ORAL [2 pts]

   Excellent    Good    Fair

Lipreading Skills (Possible Points: 4)  

   Excellent [4 pts]    Good [3 pts]    Fair [1 pt]

Camp Skills (Possible Points: 30)  

In the following list, check all that apply.    

T: activities that you can organize and teach as an expert [2 points per activity]

A: activities in which you can assist [1 points per activity]

C: you have a related certification; include a copy of your certification [3 points per activity]

   Archery

   T    A    C

   Karate

   T    A    C

   Arts and crafts

   T    A    C

   Sports:

Specify      



   T    A    C

   Drama

   T    A    C

   Swimming

   T    A    C

   Fitness and exercise

   T    A    C

   Team building

   T    A    C

   Hiking

   T    A    C

   Other:

Specify      



   T    A    C

Additional Certifications (Possible Points: 8)  

If you have one or more of the following, please provide a copy of your current certification(s).  

Cardiopulmonary resuscitation (CPR)

   Yes [2 pts]    No [0 pts]

First aid

   Yes [2 pts]    No [0 pts]

Water safety instruction or lifeguard

   Yes [2 pts]    No [0 pts]

Other:    Specify      

   Yes [2 pts]    No [0 pts]

Essay #1 (Possible Points: 15)  

What kind of role model do you think you would be? How will you serve as this role model?

     


Essay #2 (Possible Points: 15)  

Write a brief biographical sketch, including specialized training in camping and experience or training in other fields related to the position(s) for which you are applying. Attach an additional sheet of paper if necessary.

     


Education Information  

Name of school, city, state

Diploma or major, type of degree, and year

Years attended

     

     

     

     

     

     

     

     

     

     

     

     

Employment Experience  

List most recent position first.

Start date:

     


End date:

     


Position:

     


Business name and location:

     


Supervisor’s name:

     


Supervisor’s telephone number:

(   )      



Description of job responsibilities:

     


Start date:

     


End date:

     


Position:

     


Business name and location:

     


Supervisor’s name:

     


Supervisor’s telephone number:

(   )      



Description of job responsibilities:

     


Start date:

     


End date:

     


Position:

     


Business name and location:

     


Supervisor’s name:

     


Supervisor’s telephone number:

(   )      



Description of job responsibilities:

     


Start date:

     


End date:

     


Position:

     


Business name and location:

     


Supervisor’s name:

     


Supervisor’s telephone number:

(   )      



Description of job responsibilities:

     


References  

List three people who know you and your abilities. Do not include family members.  

Name (first and last)

Relationship

Email address

Phone number

     

     

     

     

     

     

     

     

     

     

     

     

Signature  

I certify that to the best of my knowledge the information given in this application is true and correct. 

Signature:

X      

Date:

     





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