If you have any questions about this application please contact:
Muneer Panjwani
Director of Youth Programs
Phone: (860) 683-1039 x102 Fax: (860) 683-1409
Mpanjwani@nccjctwma.org
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Please answer all questions.
Incomplete applications will not be processed. |
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| Name
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| Address
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| City
State
Zip
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| Telephone Number
Cell/Other Number
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E-Mail Address
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| Birthday
(mm/dd/yyyy) |
Place of Birth
City
State
Country
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| T-Shirt Size
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Are you employed?
Employer Name
Years
Position Title
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| OR Grade you will be in Next Year
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Have you ever attended the BRIDGES program?
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Have you ever applied to staff at ANYTOWN?
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Have you ever Attended ANYTOWN?
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To insure diversity at ANYTOWN
we ask that you please check any of the following that apply to you.
It is important that you check at least one box in each section.
This information is confidential and will not be disclosed or used for any other purposes.
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CLASS BACKGROUND
DISABILITIES
If yes please list
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RACE
Please check all that apply
African American/Black
Latino/a
Asian/Pacific Islander
Middle Eastern
Indigenous/American Indian
White
Biracial/Multiracial
South Asian (Indian/Pakistani, etc.)
Other
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RELIGIOUS IDENTIFICATION
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Please list specific religion in the category provided
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| SEX
SEXUAL ORIENTATION
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DO YOU HAVE ANY DIETARY RESTRICTIONS, ALLERGIES OR SPECIAL NEEDS?
Other
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Dietary Restrictions/Allergies
Special Needs
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CERTIFICATIONS
Counseling/Therapy
Nurse
Ropes Course
First Aid/CPR
Expiration
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Lifeguard
Expiration
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Other
Specify
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SKILLS
Please list any skills that you can share with ANYTOWN |
Acting
Hiking
Art
Running
Night Patrol (insomnia)
Writing
Singing
Fire Starting
Story Telling
Guitar
Sports/Gaming
Photography
Organizational Ability
Cultural Knowledge (music, history, etc.)
Languages Spoken Fluently
Public Speaking/Facilitation Experience
Other
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PLEASE ANSWER THE FOLLOWING QUESTIONS. FEEL FREE TO TYPE YOUR RESPONSES.
ALL 7 QUESTIONS MUST BE ANSWERED FOR THE APPLICATION TO BE ACCEPTED!
THERE ARE NO RIGHT OR WRONG ANSWERS!!!
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1- Why are you interested in staffing at ANYTOWN? What will you add to the experience? |
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| 2- What do you believe is the most important thing that ANYTOWN accomplishes? |
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3- In your own words define the terms diversity, prejudice and oppression? |
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4- What social justice activities have you been involved in? How have you brought your ANYTOWN experience back to your communities? |
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5- What do you hope to add to the ANYTOWN experience? Why should you be chosen to be on the ANYTOWN staff? |
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6- Being staff at ANYTOWN is not always an easy job. How would you respond, what would you say or do if… |
a- delegates in your cabin attempt to sneak out at night or you hear rumors of midnight rendezvous?
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b- delegates near you during a program are being disruptive?
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c- a delegate at ANYTOWN expresses that they don’t want to be there?
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d- a delegate reacts emotionally/passionately (crying, raising their voice, getting angry) to the discussion topic?
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e- a delegate leaves during a program or discussion group?
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f- A delegate uses derogatory or offensive language and jokes?
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7- To be selected as staff on ANYTOWN is a privilege and those who have been selected in the past have demonstrated significant interest in taking learning’s from ANYTOWN back to their schools and communities. |
a. What have you done at your school/community to create change?
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b. What impact did this have in your school/community? In other words, what did you accomplish by doing this?
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c. How else have you been involved in social justice work?
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If you have any questions about this application please contact:
Muneer Panjwani
Director of Youth Programs
Phone: (860) 683-1039 x102 Fax: (860) 683-1409
Mpanjwani@nccjctwma.org |
Please make sure you answered all questions before you submit the application.
Incomplete applications will not be processed. |
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I understand that if chosen as staff for ANYTOWN I must attend two-day staff training, as well as all six days of the Regional ANYTOWN. |
| I give permission for this applicant to attend ANYTOWN as a staff member. |
| Parent/Guardian Name: (if applicant is under 18)
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| Parent/Guardian Phone:
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IMPORTANT
By pressing the submit button below you recognize that the individual named on question number 1 is applying to staff at the Regional ANYTOWN overnight program. |
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