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Returning Vol. App.
CAMP VIVA 2012
c/o Family Services of Westchester
One Summit Avenue, White Plains, NY 10606
March 12, 2012
Dear Camp Viva Volunteer:
We hope that this letter finds you well! With the promise of warm weather, it is time to start thinking about if you plan to return to Camp Viva for another exciting, fun packed week. This August marks our 18th year of camp and we are so grateful for all our amazing volunteers (you!) who have made that possible. We hope that you are planning to join us again this year!
Please note that medical forms are mandatory for all volunteers attending Camp Viva 2012, especially the PPD results. You may send your application prior to having your physical, but please have the medical data returned before the Staff Training session in August.
If you definitely know you can or cannot make it to camp, please contact me at or 845.893.0489. I will also be reaching out in the next few weeks to touch base about your personal desires for camp and to get names of people that you know are interested in volunteering at camp.
Dates to mark on your calendar:
Staff Training: Saturday, August 11th
Camp week: Sunday, August 19th through Saturday, August 25th.
If you have any questions, please feel free to contact either of me at any time. Hope to hear from you soon.
Boom Chicka Boom!!
Mary Pat
Mary Pat Draddy, LMSW
Volunteer Coordinator of Camp Viva
845.893.0489
CAMP VIVA 2012
RETURNING VOLUNTEER APPLICATION
c/o Family Services of Westchester
One Summit Avenue, White Plains, NY 10606
Camp Viva runs from Sunday, August 19, 2012 through Saturday, August 25, 2012. It is required that all volunteers commit to being at camp for the entire camp week.
CONTACT INFORMATION:
Name: ______
Current Address: ______
Permanent Address (if different from above):
______
Home: (_____) ______Work: (_____)______
Cellular:(_____)______E-Mail: ______
WORK EXPERIENCE:
Occupation:______
Current Employer:______
CAMP EXPERINCE:
Would you like to return to job you performed at camp? ______
If no, what would you like to do instead? ______
Please rate which age group you would prefer to work with by listing your first 3 choices (1, 2, 3).
3-6 ______
7 – 10 ______
11 – 13 ______
14 – 17 ______
adult ______
Is there an age group that you are not willing to work with? ______
Would you want lead any of the following activities (instead of being a group counselor)? (Please Circle)
Arts and Crafts Musical Activities Movement Activities Sports Activities
Is there anything at camp that you would like to experience this year? ______
What special talents or skills would you like to share with Camp Viva (guitar, athletic ability, ability to run a process group, etc.)?
______
Are you certified in CPR? Yes No Are you certified in First Aid? Yes No
Have you ever had any license, certificate or employment suspended, revoked, terminated or adversely affected? If so please explain: ______
Have you ever been convicted of a crime? Yes No
If yes, please explain:
______
PLEASE READ CAREFULLY BEFORE SIGNING:
Family Services of Westchester, Camp Viva does not discriminate and considers all candidates regardless of race, creed, color, religion, gender, national origin, handicap or disability, marital status, sexual orientation or veteran’s status.
I ______, hereby authorize the investigation by Camp Viva and Family Services of Westchester, of all statements made in the application to Camp Viva. This may include checks of Public Records including motor vehicle and/or police checks and, New York State Central Register of Child Abuse and Maltreatment. I understand that my references will be checked. The above statements and the statements I made in my previous application(s) to Camp Viva are true and complete to the best of my knowledge.
I agree to uphold the rules and philosophy of Camp Viva. I understand that drugs and alcohol are strictly prohibited at all Camp Viva functions and activities. I further understand that breaking this rule is grounds for immediate dismissal.
Signature: ______
Date: ______
IN CASE OF EMERGENCY PLEASE CONTACT:
______(_____)- _____ -______
(Name/Relation to you) (Contact Number
Family Services of Westchester
Camp Viva
Confidentiality Agreement
All volunteers must strictly observe confidentiality in safeguarding the personal information of ALL CAMPERS and other volunteers. Personal information may be made available to Camp Viva staff who have a valid need to know such information but, may not be released to or discussed with others with out the written consent of the camper or volunteer in question. Files containing such information will be kept secure and will only be accessible to the staff charged with their supervision and maintenance. Failure to comply with the confidentiality requirements will result in termination of the volunteer’s services.
I have read and fully understand Camp Viva’s policy regarding confidentiality. I understand that maintaining confidentiality is vital under New York State 27-F HIV Confidentiality Law and failure to do so will result in my volunteer services being immediately terminated.
______
Signature Witness Signature
PUBLICITY RELEASE
I hereby give permission to Family Services of Westchester to use, without compensation, my name, photograph and/or any public information I have provided, or use in their public relations and/or fund raising efforts.
I realize that my photograph and/or personal information my be used by Family Service of Westchester and may appear, from time to time, in various newspapers, magazines or other news media. I may also be mentioned as someone who sponsors end endorses Camp Viva and/or Family Services of Westchester.
______
Signature Witness Signature
______
Print Name Print Name
______
Date Date
Dear Applicant,
The New York State Office of Children and Family Services requires that any applicant involved in the child care field obtain a child abuse or maltreatment clearance. As a result, all Camp Viva applicants (returning and new) are required to complete a Statewide Central Registry Form each year before coming to camp.
Has any of the information (address, roommates) changed since last year?
Yes No(Circle One)
If NO, you do not need to fill out the rest of this form.We have your information on file and will enter it into the system.
If yes, please fill out the information requested below:
1) Your NameDOBGender
2) Please list the members of your household, including their first name, last name, age, date of birth, gender and relationship to you, the applicant.
NameDOB GenderRelationship to Applicant
1) ______
2) ______
3) ______
4) ______
5) ______
3) Please provide any former addresses at which you have lived over the past 28 years, including street, city, state and zip code. Please also include the years in which you lived at these various addresses, beginning with your current address and then most recent.
AddressCityStateZipYears Resided
1) ______
2) ______
3) ______
4) ______
5) ______
CAMP VIVA 2012
VOLUNTEER
PHYSICIANS STATEMENT
A licensed physician must complete this form in full. This examination must be performed within 12 months of arrival to Camp Viva. Examination for some other purpose within this period is acceptable. Examination is for determining if volunteer is able to engage in strenuous activities.
Volunteer Name: ______
Date of Birth: ______
Height: ______Weight: ______Blood Pressure: ______
Urinalysis: ______Eyes: ______Glasses: ______
Ears:______Nose:______Throat:______
Heart: ______Lungs:______Abdomen: ______
Hernia:______Extremities:______Posture:______
Spine:______Skin:______Scalp/Hair:______
Should activities be restricted: Yes No: If yes, why? ______
______
Swimming in pool allowed: Yes No
Current Medications: Dosage and frequency:
Medication 1: ______
Medication 2: ______
Medication 3: ______
Medication 4: ______
Medication 5: ______
Special Dietary Needs: Please Describe ______
______
Other Special Needs: Please Describe ______
______
PAST MEDICAL HISTORY; Please circle the correct response;
Asthma………..……Yes NO
Hay Fever……..……Yes No
Seizures……….……Yes . No
Diabetes………….…Yes No
Lung Infection…...... Yes No
Diarrhea/Frequent…..Yes No
Chronic Pain………..Yes No; location of pain ______
Hearing difficulties…Yes No
Heart Disease………..Yes No
Heart Murmur……….Yes No
Hx of Chicken Pox…..Yes No
ALLERGIES: PLEASE BE SPECIFIC AND LIST ALL KNOWN ALLERGIES
Environmental ______
Food ______
Insect Stings ______
Medication(s) ______
TURBERCULOSIS
DATE AND RESULT OF MOST RERCENT PPD: ______
Operations, Illnesses, Hospitalizations, or serious injuries: (please list all)
______
I ______MD, have examined ______and
have reviewed his/her health history. It is my opinion that this person is physically able to engage in camp activities except as noted above. I will contact Camp Viva or the Camp Medical Director, with any changes in status in the 2 weeks prior to camp.
Physician’s Signature: ______Date of Exam: ______
Print Name: ______
Contact Number: ______
*Please return completed to: Camp Viva c/o Family Services of Westchester
1 Summit Avenue, White Plains NY 10606
CAMP VIVA 2012
c/o Family Services of Westchester
One Summit Avenue, White Plains, NY 10606
Volunteer Checklist:
All the steps must be completed to become a Camp Viva volunteer.
Completed and signed application
Completed SCR form
Completed and signed Confidentiality Agreement
Completed Medical form and signed by a medical professional
Complete training program
Get ready to have a really fun and fulfilling week!!
If you have any questions, please contact Mary Pat Draddy, the volunteer coordinator at or 845.893.0489.