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Has your Drivers License ever been revoked?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________________________