MAINE TU TROUT CAMP STAFF AND INSTRUCTOR APPLICATION

 

First Name_________________________  MI_____  Last Name_______________________________

Please Circle the areas you are interested in helping with:

Fish Habitat                  Fish Dissection              Fish Life Cycle               Conservation

Native Fish                    Water Quality               Fly Casting                    Fly Tying

1 on 1 Fishing               Wading Safety              Knot Tying                    Overnight Supervision

Trout Unlimited Chapter__________________________________  Memer Since__________________

SSN_______________________    DOB_____________________ Drivers License #_________________

Address_____________________________________________________________________________

City_______________________________________ State____________ Zip Code_________________

Home/Cellular Phone________________________ Email_____________________________________

Gender___________  Occupation_______________________ Employer_________________________

Business Address______________________________________________________________________

City______________________________________ State____________   Zip Code__________________

TU Offices or Training___________________________________________________________________

Youth Group Experience_________________________________________________________________

Other Skills/Knowledge__________________________________________________________________

References – Name and Phone Number

1.___________________________________________________/________________________________

2.___________________________________________________/________________________________

3.___________________________________________________/________________________________

Additional Information (Circle, explain on back if yes)

Has your Drivers License ever been revoked?     Yes       No

Have you ever been convicted of a criminal offense?      Yes       No

Have you ever been charged with child neglect or abuse?           Yes       No

Do you use illegal drugs?           Yes       No

Other than the above, is there any fact or circumstance involving you or your background that would call into question your being entrusted with supervision, guidance, or care of young people?        Yes         No

The information I have provided may be verified if necessary by contacting persons or organizations named in the application or by contacting any person or organization that may have information concerning me or by conducting a criminal background check.  I agree to release and hold harmless from liability any person or organization that provides information.  I also agree to hold harmless Trout Unlimited, its members and any volunteers associated with them.  I affirm that the information I have given on this form is true and correct.

Signature_____________________________________________ Date________________________