Camp Staff Application for Camp Notaclotamongus

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 State ZIP Code
Years Known*
Name of Reference #2*
Phone #*
Address
Street Address Address Line 2 City State ZIP Code
Years Known*

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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?

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Doctor's Name:*
Doctor's Phone # and Exchange #*
Date of your last physical examination:*
Date Format: 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

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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
Date of last Tetanus booster/DTaP/TdaP*
If you have a bleeding disorder, please answer the following questions.
Diagnosis/Severity/Type:
History of inhibitor?
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.)*
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*
Date Format: 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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Camp Staff Application for Camp Notaclotamongus

Step 1 of 6

In an emergency, notify the following.

Staff T-Shirt Size:

Personal References: List two personal references (individuals not related to you) who can vouch for your ability to be a camp volunteer.

ALLERGIES

DIETARY REQUIREMENTS

“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.

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.

If you have a bleeding disorder, please answer the following questions.

Behavior Expectations When Camp Staff is used below it is defined as GHA staff, medical personnel, counselors, or day volunteers.