• Personal Information
• Name* First Middle Last
• Preferred Name*
• Cell Phone*
• Date of Birth* Date Format : MM slash DD slash YYYY
• Address* Street Address Address Line 2 City State ZIP Code
• Home Phone*
• Email Address*
• Position Applying for :
• Certifications :
• CPR Expires
• ServSafe
• ServSafe
• ServSafe Expires
• Basic First Aid
• Basic First Aid
• Basic First Aid Expires
• Lifeguard
• Lifeguard
• Lifeguard Expires
• Water Safety Instruction
• Water Safety Instruction
• Water Safety Instruction Expires
• Wilderness CPR
• Wilderness CPR
• Wilderness CPR Expires
• Legal Violations :
• If yes, please explain :
• Employment History

Please List up to three past employers, assignments or volunteer activities, starting with the most recent.

• Employer #1
• Company Name : *
• Phone*
• Supervisor*
• Dates of Employment*
• Work Performed*
• Address* Street Address Address Line 2 City State ZIP Code
• Employer #2
• Company Name :
• Phone
• Supervisor
• Dates of Employment
• Work Performed
• Address Street Address Address Line 2 City State ZIP Code
• Employer #3
• Company Name :
• Phone
• Supervisor
• Dates of Employment
• Work Performed
• Address Street Address Address Line 2 City State ZIP Code
• If previously employed by another summer camp, please provide the following information :
• Camps & Locations
• Position(s) :
• Date(s) :
• Please provide two personal references :
• Reference #1
• Name*
• Cell Phone*
• Email*
• Reference #2
• Name*
• Cell Phone*
• Email*
• Verification :

I further hereby release all references and prior employers from any liability for information provided in good faith. I hereby affirm and acknowledge, by signing below that all of the information in this employment application is true and complete.

If I move forward in the hiring process, I agree to sign a release form to have a background check run on my background.

I further understand that if I am offered a position at Mirror Lake Retreat, I will carefully read the Mirror Lake Retreat Staff Policy Manual and agree to follow these policies fully during my time on staff at MLR.

I understand that if hired I will be committing myself to a position of service and that my actions should reflect my willingness to serve.

• Applicant's Signature*
• Date* Date Format : MM slash DD slash YYYY
• Enter your Name*
• Parent / Guardian Signature (if under 18) :
• Date Date Format : MM slash DD slash YYYY

Last updated : 2024-03-08