Founders: Frank Coleman, Oscar J. Cooper, Ernest E. Just, Edgar A. Love

Omega Psi Phi Fraternity, Inc.

SIXTH DISTRICT

NORTH CAROLINASOUTH CAROLINA

SUMMER CAMP COUNSELOR APPLICATION

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Email Address (required) Signature (required**)Social Security Number (required)

NAME ______DATE OF BIRTH ______

COLLEGE ATTENDING/ATTENDED ______

LOCAL ADDRESS ______CITY/ST/ZIP ______

HOME ADDRESS (if different from local address) ______

CELL PHONE w/AC ______HOME PHONE w/AC ______

CLASSIFICATION (if in college) ______MAJOR ______

GPA (if in college) ______CHAPTER (if a member of the Fraternity) ______

CONTROL NUMBER (if a member of the Fraternity) ______ARE YOU FINANCIAL? ______

REFERENCES:Below give the names, addresses and telephone numbers of three persons not related to you who would write or give you a recommendation. Two must be OMEGA MEN and the third should be one of your instructors. Under the instructor’s information, be sure you list the subject s/he is teaching or has taught you.

(1) NAME ______ADDRESS ______

CITY/ST/ZIP ______PHONE w/AC ______

(2) NAME ______ADDRESS ______

CITY/ST/ZIP ______PHONE w/AC ______

(3) NAME ______ADDRESS ______

CITY/ST/ZIP ______PHONE w/AC ______

SUBJECT(S) ______

** By signing above, you are giving the Sixth District of Omega Psi Phi express permission to conduct a background check to confirm the accuracy of the information provided and assist in determining your fitness to serve as a camp counselor.

Since you are applying for a counselor position, indicate why you are applying and list the unique qualifications, talents, special skills, and personal characteristics you possess that make you a responsible choice. Do not leave blank and make every effort to write the best statement you can. continue on reverse side if necessary. (required)

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Have you ever been arrested? If so, provide complete details below. (required)

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Are you or have you ever been under the supervision of the criminal justice system including, but not limited to, probation, parole, deferred prosecution, registered sex offender or similar status? If so, provide complete details below. (required)

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Do you have any restrictions or limitations, physical or otherwise, that will affect your ability to perform the duties of a camp counselor? (required)

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The dates for the 6th District Summer Camp are July 2, 2017 through July 7, 2017, at YMCA Camp Hanes, King, North Carolina. Camp counselors report on Saturday, July 1, 2017. If you wish to be considered for a counselor position, you must submit a completed application no later thanJune 1, 2017. Mail your completed application to:

Bro. Melvin T. Miller

422 Sesqui Trail

Columbia, South Carolina 29223.

Should you need additional information, you may also reach Bro. Miller at or 803-609-7314. Thank you very much for your willingness to serve the Sixth District as a Summer Camp Counselor.

Attention: Do not apply if you are not 100% sure that you will be available for work the entire week as indicated above-24 hours a day for the seven days.

Note: Brothers of Omega Psi Phi will receive priority in the selection of camp counselors.

Note: Camp counselors who are Brothers of Omega Psi Phi will only be paid if the counselor’s chapter has satisfied its obligation to send the requisite number of campers to camp. Camp counselors will not be paid if their chapter has failed to meet its obligation to send campers to camp.

Revised: January 2012, updated December 2016