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Camp Staff Application for Camp Notaclotamongus
Camp Staff Application for Camp Notaclotamongus
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Last Name:
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First Name:
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Date of Birth
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MM slash DD slash YYYY
Gender
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Male
Female
Address
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Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
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Armed Forces Americas
Armed Forces Europe
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State
ZIP Code
Phone #
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*
Home
Work
Cell
Alternate Phone #
Home
Work
Cell
Email address
*
In an emergency, notify the following.
Emergency Contact's Name
*
Phone #
*
*
Home
Work
Cell
Employer Information - Company: (if unemployed put n/a)
*
Job Title: (If unemployed put n/a)
Dates employed:
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Staff T-Shirt Size:
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Adult S
Adult M
Adult L
Adult XL
Adult 2L
Adult 3XL
Position I am Applying For:
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Counselor
Med-Shed (Nurse/Doctor)
Day Volunteer (Activity Staff Member)
Other
• All Attendees, including counselors, medical staff, and volunteers must pass criminal background checks • Counselors must be 18 years of age or older and have two or more years of experience as an LIT • Counselors must be able to attend all days of camp, including staff orientation June 2 – 6, 2020 • Activity staff and day volunteers will be responsible for their assigned activity at camp and other duties as requested. Other Positions include, Camp Photographer, Lifeguard, Runner, Camp DJ, Fishing, etc.
List any special skills and/or talents that you would be willing to share/teach:
Insurance Company
*
Policy #
*
Name of person who carries the plan
*
Describe previous camp volunteer experience and/or experience as a camper.
List any other youth volunteer experience.
Do you have a child attending this camp?
*
Yes
No
Describe your relationship with the bleeding disorders community and/or industry?
Personal References: List two personal references (individuals not related to you) who can vouch for your ability to be a camp volunteer.
Name of Reference #1
*
Phone #
*
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Years Known
*
Name of Reference #2
*
Phone #
*
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Years Known
*
ALLERGIES
*
No known allergies
I have allergies & I will list below
I am allergic to:
*
Food
No food allergies
Food: Allergy Reaction Treatment
I am allergic to:
*
Medication
Nothing
Medication: Allergy Reaction Treatment
I am allergic to:
Other
Other: Allergy Reaction Treatment
DIETARY REQUIREMENTS
Any dietary concerns?
Date of your last physical examination:
*
MM slash DD slash YYYY
List any significant illnesses within the past year:
Please describe any significant medical conditions:
List any physical limitations:
“Medication” is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies.
Any medication that your Medical Provider requires to be administered at camp must be in its original pharmacy container labeled with the name of the person, name of medication, dosage, and frequency of administration.
Medication
*
I will not take any daily medications while attending camp.
I will take the following daily medications while at camp:
Name of Medication
Date started
Reason for taking it
Name of second Medication (if applicable)
Date started
Reason for taking it
How it is given
Name of third Medication (if applicable)
Date started
Reason for taking it
2. A copy of the health form will be kept in the Camp Health Center during camp session. Please Note: ALL COUNSELOR MEDICATIONS brought to camp are required and must be kept in the secured area at the Health Center. Your medications will be accessible to you 24 hours/day. If you have any questions regarding medications at camp, please notify the camp director.
2. I release this form, with my medical information, to GHA’s Camp Notaclotamongus, Med Shed Staff and other medical professionals deemed necessary for emergency medical care.
Signature
*
Have you been immunized for any of the following?
*
MMR (Measles, Mumps, Rubella)
Chicken Pox
Whooping Cough (Pertussis)/DTap/TdaP
I have never been immunized
Tetanus booster/DTaP/TdaP
Covid Vaccination (a copy will need to be sent to GHA via email or text)
Year of last Tetanus booster/DTaP/TdaP
*
If you have a bleeding disorder, please answer the following questions.
Diagnosis/Severity/Type:
History of inhibitor?
n/a
Yes
No
Please list factor treatment product routinely used:
DISCLOSURE As part of our volunteer hiring background and investigation, we may obtain consumer reports or prepare an investigative consumer report. The investigative consumer report may consist of contacting all listed prior employers to verify your employment history. It may also include, but not be limited to, criminal history reports and driving history records. Under the provisions of the Fair Credit Reporting Act (15 USC at 1681-1681u) as amended, before we can seek such reports, we must have your written permission to obtain the information. You have the right, upon written request, to a complete an accurate disclosure of the nature and scope of the investigation.
AUTHORIZATION TO RELEASE INFORMATION **I hereby do authorize you to contact my current employer for Employment and Reference Verifications (This will authorize immediate inquiries to the Human Resources Department and to any listed supervisors or references in the Employment/Reference Section of your application.)
*
Yes
No
The following POLICIES are STRICTLY enforced at Camp Notaclotamongus: Marketing products or soliciting business of any kind is not allowed at camp. This includes identifying yourself with a company or product; distributing business cards or brochures; and wearing of apparel, name tags or any other means of identifying a representative with a specific company. I will not disclose to any person any information obtained as a result of my participation in this camp. I will not solicit addresses or phone numbers of patients and/or families and will not use any information obtained because of my participation in camp, for any financial or commercial gain. I acknowledge that due to the confidential nature of Camp Notaclotamongus, I am not allowed to take pictures from my own personal camera or device, post any photos to Facebook or other social networking sites regarding activities or attendees at Camp Notaclotamongus. I understand that in order to set an example for the campers and promote safety and health, drinking alcoholic beverages is not allowed at camp or during any out-of-camp activity and smoking is never allowed in front of any campers and only permitted in the designated smoking area (outside of camp). Staff agree to wear designated uniform at camp, when applicable and appropriate clothing, otherwise. No offensive clothing, no risqué clothing, no clothing with alcohol or tobacco products, no oversized or baggy clothing allowed. Men should wear boxer style bathing suits and ladies should wear one piece athletic style, no bikinis or thongs are allowed. If ladies do not have a one-piece bathing suit, an acceptable, non see-through cover up may be worn over the bikini. Counselors are expected to attend the entire length of camp, including Camp orientation. Camp Notaclotamongus is run with limited staff. Last minute cancelations put us in a bind and are not acceptable. Exceptions to this policy can only be made by the Camp Director. VIOLATION OF THESE POLICIES WILL JEOPARDIZE VOLUNTEER’S ABILITY TO PARTICIPATE IN FUTURE CAMPS! ACKNOWLEDGEMENT AND SIGNATURE REQUIRED In making the volunteer application for GHA Camp Notaclotamongus, I state that the foregoing information is complete and accurate. I authorize the release of information regarding my qualifications, background, and fitness for this position to Camp Notaclotamongus or its agents or employees, including the Hemophilia Treatment Centers and Gateway Hemophilia Association. I release from all liability all individuals of organizations that provide information about me regarding this application. I consent to any test that may relate to my fitness for this position, including tests for drugs and alcohol. I consent and request that all such persons or agencies accept a photocopy of this authorization as valid authorization to give such information or records.
Date
*
MM slash DD slash YYYY
Signature
*
Behavior Expectations When Camp Staff is used below it is defined as GHA staff, medical personnel, counselors, or day volunteers.
1. Camp Staff will treat everyone in the camp community with respect at all times and show respect for others’ personal belongings, privacy, and feelings. 2. Camp Staff will follow directions and abide by camp rules. 3. Camp Staff will not be involved with alcohol use, illegal drugs, weapons, vandalism, theft, or any other illegal behavior. 4. Camp Staff will use appropriate language; profanity will not be tolerated. 5. Camp Staff will remain on the camp site unless on an escorted approved camp activity or for a medical emergency that requires transportation to an outside medical facility. 6. Camp Staff will respect the camp facility and its equipment. Camp Staff will be responsible for all damage due to negligence or intentional vandalism. 7. Camp Staff will sleep in their assigned cabins each night
Signature
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