Hospice of Central Virginia

Camp Rainbow Application 2017

Thank you for your interest in being a Camp Rainbow Volunteer! We hope that volunteering for Camp Rainbow will be a life-changing experience for you as you guide a grieving child through an amazing weekend of fun and comfort. Camp Rainbow is brought to you by Mary Washington Hospice Support Care.

Camp Rainbow is a weekend day camp for children (Little Buddies) ages 6-14 who have lost a loved one. The goals for Camp Rainbow are to help children understand death and dying, learn to express grief in a healthy way and learn to cope with loss. Art, music, and dance therapy are used to promote these goals alongside traditional camp activities like hiking, kayaking and fireside chats. To provide a rewarding experience, each Little Buddy will be paired with the same Big Buddy for both days.

Camp Rainbow will be held at the Virginia Outdoor Center/

Friends of the Rappahannock

3219 Fall Hill Avenue,

Fredericksburg, VA 22401

Saturday, April 29 and Sunday, April 30

You must be 14 years of age or older to be a Camp Rainbow volunteer.

Please complete and return the enclosed packet as soon as possible.

Your paperwork must be turned in prior to training.

Please Circle Desired Position:

Big Buddy

Activity Assistant

Grief Session Facilitator

Meal Prep Assistant

R.N./Medic

Operations Assistant

Circle T - Shirt Size (Adult) S M L XL XXL XXXL

Previous Camp Rainbow Experience:
Experience working with children:
Other children’s camp experience (include names and dates):
Explain why you wish to volunteer at Camp Rainbow:
Are you committed to stay the entire time, both days?
Other than English, what languages do you speak? Could you interpret in that language?
Age group preference:

Please complete the above form and attachedapplication and return both to

Mary Washington Hospice

Attention: Volunteer Department

2300 Fall Hill Ave, Suite 401

Fredericksburg, VA 22407

Camp Rainbow Specific Training is required for ALL Camp Rainbow Volunteers to include returning volunteers.

All those involved in Camp Rainbow are requiredto attend one of these sessions. If you are not already a trained volunteer with Mary Washington, your training will begin an hour ahead of these times so that you may complete our new volunteer orientation.

Saturday, April 1from 9:00 a.m. to Noon
Saturday, April 8from 9:00 a.m. to Noon

Monday, April 10 from 6:00 p.m. to 9:00 p.m.

Light refreshments will be served.
Training Location:

Virginia Outdoor Center,

3219 Fall Hill Ave.

Fredericksburg, VA 22401

To ensure your name is on the list for the required training,please indicate which training date aboveyou are able to attend by contacting Kathryn Wall, Volunteer Program Support Assistant, @ or 540-741-3595.

CampRainbow will be held at the Virginia Outdoor Center/

Friends of the Rappahannock

3219 Fall Hill Avenue,

Fredericksburg, VA 22401

Saturday, April 29 and Sunday, April 30 with a pep rally on Friday evening April 28th from 6:00-8:00 p.m.

Big Buddies must commit to all days of Camp Rainbow.

Please keep this page for your information.

For more information on Camp Rainbow, please contact Kathryn J. Wallat 540-741-3595 or

Mary Washington Healthcare
Hospice Support Care
Volunteer Application Form
2300 Fall Hill Avenue
Fredericksburg, VA 22401
BUS: (540) 741-1667
FAX: (540) 741-1841
PERSONAL INFORMATION(Please print clearly)

Name:______Date: ______

Address:______

City: ______State/Zip: ______

Telephone:Home:Work:______

Cell:______Email:________

Date of birth: ___/___/____ Social Security Number: ______

How long at this address? ____years ____month Are you 18 years or older?Y or N

The best way to contact me:

 Home Work Cell e-mail

I am available (check all that apply):

Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday
Mornings
Afternoons
Evenings

How much time do you have to volunteer? ______

I am a US citizen: Yes ____ No ____ I have been a Virginia resident for______years.

Person to be notified in case of an emergency: ______

RelationshipHome ( )Work ( )

Occupation/Employer: ______

Address: ______City: ______State/Zip: ______

If retired, from what occupation: ______

Education:

Level of Education / City and State of Institution / Years of Study / Completed Y/N / Degree or Certification
High School
Associate Degree
Bachelor Degree
Graduate Degree
Doctorate
TechnicalSchool
ProfessionalSchool
Other(s)

Are you currently in school?  Yes, full-time Yes, part-time No

Typing Speed: ______WPMMicrosoft Office:  Yes  No

Professional Licensure:

License/Certification / State / License Number / License Issued / License Expires / Temp or Perm

Bereavement History:

RELATIONSHIP / DATE OF DEATH / YOUR
AGE / CAUSE OF DEATH
AREAS OF INTEREST (Check all that apply)

Volunteer Opportunities:

Family Expressions Grief Support Group Communication/Marketing

 Kids Helping Kids In-School Grief ClubPublic Relations

Camp Rainbow (Grief Camp) Fundraising

Special Events PlanningMass Mailings

Administrative/Office Support Working with Children

Landscaping/Gardening/Cutting Grass Other______

EXPERIENCE AND QUALIFICATIONS

What type of work have you done in the past?

Have you done any volunteer work?

 Yes, currentlyyes, in the past No

If yes, please specify ______

Are you fluent in any languages? ______If yes, please list ______

Please describe any life and/or work experiences or training(s) which may help you as a hospice volunteer: ______

______

Do you have a valid driver’s license?YesNo what state? ______

In the past three years have you been convicted of more than three moving violations?

YesNo

In the past three years have you been in an accident in which you were found to be at fault? Yes No

In the past seven years have you been convicted of any major driving offense (DWI, reckless driving, etc.)? Yes No

Have you ever been convicted of any criminal violation of law (including minor traffic violations), or are you now under pending investigation or charges of violation of criminal law? Yes No

If yes, please describe circumstances, date, and jurisdiction______

Have you been the subject of any adverse action(s) by any duly authorized sanctioning or disciplinary agency for either conduct based or performance based action? Yes No

If yes, please explain______

In the last three years, have you ever knowingly used any narcotics, amphetamines or barbiturates, other than those prescribed to you by a physician? Yes No

If yes, please describe______

References

Have you ever worked for Mary Washington Healthcare or a Mary Washington Healthcare entity? Yes No

Are you eligible for employment in the United States?YesNo

Do you have relatives employed at Mary Washington Healthcare?YesNo

If yes, Name of relative: ______

Please list three references (use form provided to send to your three references to complete.):

1.Name:______

Address: City:______

State: Zip Code: Phone:______

In what capacity and for how long has this person known you?______

______

2.Name:

Address: City:______

State: Zip Code: Phone:______

In what capacity and for how long has this person known you? ______

______

3.Name:______

Address: City:______

State: Zip Code: Phone:

In what capacity and for how long has this person known you?______

______

AGREEMENT AND INFORMATION RELEASE

Please read the following carefully before signing.

I certify that the answers and statements given by me in response to this application are true and correct with out consequential omissions of any kind whatsoever. I agree that Mary Washington Healthcare shall not be liable in any respect if my volunteer position is terminated because I have falsified statements, or answers, or have made omissions on this application or on supporting documentation.

If I volunteer, I hereby agree to abide by the rules and policies of my organization and facilities in which I volunteer as a Hospice Volunteer. I understand that noting contained in the application or during an interview is intended to create a contract between Mary Washington Healthcareand myself for either employment or the provision of any benefits. If a relationship is established, I understand that I have the right to terminate my volunteer position at any time with proper notice, and that Mary Washington Healthcare retains the right to terminate my volunteer position at any time at its discretion. Volunteering is not considered finalized until the Volunteer Coordinator has received:

a satisfactory check of references, supporting transcripts and license or registry certification, and criminal background check;
a Tuberculosis test must be administered and read,
proof of age and citizenship, and all documents necessary to complete federal and state regulatory requirements

I hereby authorize Mary Washington Healthcareor the appropriate subsidiary to contact any school, listed reference, law enforcement agencies and persons who may aid Hospice Support Caredetermining my suitability for a volunteer position unless otherwise noted. Additionally, I release those individuals and/or organizations contacted from all liability whatsoever for providing the requested information.

Date:Signature:

PARENTAL OR GUARDIAN CONSENT

My daughter/son ______has my permission to serve as a Hospice Support Care Teen Volunteer.

SIGNATURE OF PARENT: ______DATE: ______

Volunteer opportunities are available to all qualified applicants without regard to race, color, religion, gender, national origin, age, disability, or sexual orientation. Hospice shall reserve the right to deny appointment of prospective volunteers as a result of the application, interview and/or training process.

applica.vol (HSC)

Attention: Volunteers

The attached (3) Reference Forms should be returned to the Volunteer Department after they have been completed.No later than March 31, 2017

Please ensure the information for your reference is available on the form, their name, address and phone # in this section at the top of the form:

TO:DATE:

Please ensure that your name is filled in at the section of the form where it states:

Your name has been given as a personal reference by ______(fill in your name neatly written or typed.)

Thank you for your assistance.

MARY WASHINGTON HEALTHCARE

HOSPICE SUPPORT CARE

VOLUNTEER PERSONAL CONFIDENTIAL REFERENCE FORM

****************************************************************************************

TO:DATE:

Your name has been given as a personal reference by ______

The above named person has applied to be a VOLUNTEER with our program and has given your name as a personal reference. We would greatly appreciate your confidential evaluation of the above-referenced person as to his/her character and ability. Would you kindly fill out and return this information at your earliest convenience.

Hospice Support Care (HSC) provides support to people who are grieving. Support services are provided by trained professional. Hospice Support Care uses trained volunteers to provide support to children and families during the bereavement process. Our volunteers work directly with families who are actively grieving. They provide a “listening ear” and support to families at a very stressful time in their lives. Volunteers are also used to provide support to administrative/office staff and to assist with special events which are held by our agency.

Your comments will help our program serve our families more effectively and will be considered confidential.

RATE APPLICANT / EXCELLENT / GOOD / AVERAGE / POOR
Dependability
Emotional Stability
Interpersonal Skills
Punctuality

In what capacity have you known the applicant and for how long?

Volunteers work with family members under stress. Has this applicant demonstrated stability and strength of character which would permit them to cope with this pressure? YES NO DO NOT KNOW

Please comment:

Volunteers work with a variety of people from various religious, ethnic, and cultural backgrounds. Do you feel this applicant demonstrates the ability to be non-judgmental when encountering persons with varying beliefs, values, and/or customs? YES NO DO NOT KNOW

Please comment:

Volunteers work with children of all ages. Do you feel this applicant demonstrates the ability to work closely with children?

Please comment:

What personal qualities do you feel this applicant demonstrates that would assist him/her in being a volunteer for HSC?

Please comment:

If you prefer to discuss this candidate confidentially over the telephone, or would rather convey your impressions personally, please note your phone number: ( ) or call Raquel Woodard, Volunteer Coordinator for Mary Washington Hospice at (540) 741-3580.

Please return this form to; Volunteer Coordinator, Mary Washington Hospice, 2300 Fall Hill Avenue, Fredericksburg, VA 22401.

SignatureDate

voll-ref.frm (HSC)

MARY WASHINGTON HEALTHCARE

HOSPICE SUPPORT CARE

VOLUNTEER PERSONAL CONFIDENTIAL REFERENCE FORM

****************************************************************************************

TO:DATE:

Your name has been given as a personal reference by ______

Your comments will help our program serve our families more effectively and will be considered confidential.

RATE APPLICANT / EXCELLENT / GOOD / AVERAGE / POOR
Dependability
Emotional Stability
Interpersonal Skills
Punctuality

In what capacity have you known the applicant and for how long?

Volunteers work with family members under stress. Has this applicant demonstrated stability and strength of character which would permit them to cope with this pressure? YES NO DO NOT KNOW

Please comment:

Volunteers work with children of all ages. Do you feel this applicant demonstrates the ability to work closely with children?

Please comment:

What personal qualities do you feel this applicant demonstrates that would assist him/her in being a volunteer for HSC?

Please comment:

Please return this form to; Volunteer Coordinator, Mary Washington Hospice, 2300 Fall Hill Avenue, Fredericksburg, VA 22401.

SignatureDate

voll-ref.frm (HSC)

MARY WASHINGTON HEALTHCARE

HOSPICE SUPPORT CARE

VOLUNTEER PERSONAL CONFIDENTIAL REFERENCE FORM

****************************************************************************************

TO:DATE:

Your name has been given as a personal reference by ______

Your comments will help our program serve our families more effectively and will be considered confidential.

RATE APPLICANT / EXCELLENT / GOOD / AVERAGE / POOR
Dependability
Emotional Stability
Interpersonal Skills
Punctuality

In what capacity have you known the applicant and for how long?

Volunteers work with family members under stress. Has this applicant demonstrated stability and strength of character which would permit them to cope with this pressure? YES NO DO NOT KNOW

Please comment:

Volunteers work with children of all ages. Do you feel this applicant demonstrates the ability to work closely with children?

Please comment:

What personal qualities do you feel this applicant demonstrates that would assist him/her in being a volunteer for HSC?

Please comment:

Please return this form to; Volunteer Coordinator, Mary Washington Hospice, 2300 Fall Hill Ave, Suite 401, Fredericksburg, VA22401.

SignatureDate

voll-ref.frm (HSC)