Volunteer Application s9

Volunteer Application

Date Last Applied/Updated/Verified: Click here to enter a date.

Everyone 18 or older must submit to a background check to be considered as a volunteer

Background Check (if over 18)

☐ Yes I am willing to submit to a background check.

☐ No I am not willing to submit to a background check.

Everyone must submit the Medical Information Form.

☐ My Medical Information Form is included with this application.

If you are under the age of 18 you must include a copy of your Immunization Records.

☐ A Copy of my Immunization Records is included with this application.

References

1.  Name: ______
Address or E-mail Address: ______.
Phone: ______.

2.  Name: ______.
Address or E-mail Address: ______.
Phone: ______.

3.  Name: ______.
Address or E-mail Address: ______.
Phone: ______.

Parent/Guardian

1.  Name: ______.
Address or E-mail Address: ______.
Home Phone: ______.

Work Phone: ______.

Cell Phone: ______.

2.  Name: ______.
Address or E-mail Address: ______.
Home Phone: ______.

Work Phone: ______.

Cell Phone: ______.

Person to Notify in Case of Emergency

A.  Name: ______.

Relationship: ______.

Home Phone: ______.

Cell Phone: ______.

Work Phone: ______.

E-Mail Address: ______.

Disclaimer / Consent

☐ Should it become necessary for my child/myself to have medical care, I hereby give authority to Camp Opportunity, Inc to use its best judgment in obtaining medical care for my child/myself, including to hospitalize, secure proper treatment for, and/or to order and secure necessary related transportation and driver, injections, anesthetics or surgery for my child/myself. I agree to be responsible for any medical expenses incurred by me or by the camp on behalf of my child/myself. I understand that in the event of an illness or accident, Camp Opportunity will make all reasonable efforts to notify me as soon as possible.

☐ I hereby waive, release and absolve and agree to indemnify and save harmless the camp and their respective officers, employees and agents from all liability arising from my child’s/my participation in the camp program, except such as results solely from its or their willful neglect or willful default. I confirm that my child/myself is capable of participating safely in the full program including all activities unless I advise you otherwise in writing and I acknowledge that such participation involves risks and hazards incidental thereto all of which are assumed by me.

☐ To the best of my knowledge, I, the undersigned, have fully disclosed all medical, psychological and/or emotional problems or concerns, and I affirm that the information contained in this medical form is complete, true and accurate. In the event that the above information should change, I will disclose such changes in writing to the camp without delay.

☐ I understand that my responsibilities as a camp counselor will include, but not be limited to, working one-on-one with an individual camper who is assigned to me. I understand that my responsibilities include being with the child for the entire week at camp and that the expectation is for me to provide a nurturing and supportive environment for him or her. I understand that my responsibilities also entail me being a team player and supporting the mission of the Camp Opportunity community.

☐ I understand that Camp Opportunity has a no tolerance policy regarding illegal drugs and alcohol, even for those of legal drinking age. I will remain substance-free when participating in all camp opportunity events and will not have them in my possession when at Camp-sponsored activities. If I suspect that anyone at Camp Opportunity activities is using or has them in their possession, I will notify staff immediately.

☐ I will be mindful of and use discretion regarding my social media accounts, posts, pictures, etc., as Camp Opportunity members and youth may have access to my postings. Additionally, I will not post my whereabouts when at Camp Opportunity events on any social media in order to better safeguard the wellbeing and anonymity of the campers.

☐ By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, and/or other misrepresentations made by me on this application, or any violations of these policies, may result in my immediate dismissal. Further, I agree to comply with rules set forth at orientation.

Volunteer Agreement

Name (printed): ______.

Signature: ______. Date: ______.

☐By signing above and/or checking this box, I acknowledge that the Volunteer understands and agrees to the terms on Page 3.

Parent/Guardian Agreement

If volunteer is 18 years or younger, parent or guardian signature gives permission to take volunteer off grounds for camp activities.

Signature: ______. Date:______

☐By signing above and/or checking this box, I acknowledge that the Parent/Guardian understands and agrees to the terms on Page 3.

Our Policy

Camp Opportunity was formed as a non-denominational faith-based organization devoted to helping children in need. One tenet of the camp program is that the incorporation of certain religious ideas may benefit the campers. As such, the idea of a God or Creator may be introduced into some lessons and each day ends with a prayer of thanks. Volunteers are not required to profess a belief in God. People at camp do not preach to or try to convert anyone and some of our best volunteers are not religious.

It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender or gender identity, sexual preference, age, or disability. Thank you for completing this application form and for your interest in volunteering with us.

Optional Donation

Camp Opportunity is a Non-profit organization that relies exclusively on grants and private donations to support the rising annual costs of our program. Campership alone is now up to $900 per child. While many other volunteer organizations and Non-profits require mandatory application or participation fees, all administrative expenses, and room & board for volunteers of Camp Opportunity are 100% covered by our organization. If interested, we ask that you please include a $20, non-mandatory suggested donation with your application to offset some of the costs associated with volunteer recruiting and other camp program costs. Also, if you, your employer, or community is interested in collecting/contributing additional donations, we welcome you to do so. Thank you!

☐ I have included a $______donation with my application.

HASHAWHA ENVIRONMENTAL CENTER RELEASE

In return for the admission of ______(name of volunteer),

into the Hashawha Environmental Appreciation Center, I hereby Release Carroll County and its officers, agents, employees, and volunteers from all actions, causes of action, damages, claims, or demands which I, for myself or on behalf of another, or my successors may have against them for any personal injuries or illnesses which occur

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while ______(name of volunteer) is attending the Hashawha Environmental Center

I have read this Release and understand all of the Hashawha policies and regulations and understand the terms. I execute it voluntarily and with full knowledge of its significance.

I have executed this Release on the day and year written below.

Dates of Visit: ______through ______

Name of Volunteer: ______.

Signature: ______.

☐ By signing above and/or checking this box, I acknowledge that the Volunteer understands and agrees to the aforementioned terms.

Parent or Guardian Name (if under 18): ______.

Parent or Guardian Signature (if under 18): ______.

☐ By signing above and/or checking this box, I acknowledge that the Parent/Guardian understands and agrees to the aforementioned terms.

Date: ______

Camp Opportunity Medical Information Form for: ______

Emergency Contacts

Primary Care Doctor ______Phone ______

Dentist ______Phone ______

Non-Parent Adult ______Phone ______

Insurance Information

Insurance Carrier ______

Insurance Policy Number ______

Medical Information

Disease History

Current Health Conditions

Camp Opportunity Sunscreen Release (if under 18)

☐I hereby authorize my child to use sunscreen at Camp Opportunity

☐I hereby authorize camp staff to assist my child in the application of sunscreen.

☐I agree that I will provide sunscreen for my child to use at camp.

Brand: ______. SPF: ______.

Parent Name: ______.

Parent’s Signature: ______.

☐By signing above and/or checking this box, I acknowledge that I understand and agree to the aforementioned terms and conditions.

Date: ______

Current Medications

Volunteer carries:

☐Inhaler ☐Epi Pen ☐Ana-Kit ☐Medic-Alert Bracelet, for: ______.

Additional Medications:

Name: ______. Dosage: ______.
Reason for Medication: ______.

Name: ______. Dosage: ______.
Reason for Medication: ______.

Name: ______. Dosage: ______.
Reason for Medication: ______.

Additional Medications / Details:

Click here to enter text.

Allergies:

☐Medication(s): ______. Reaction: ______.

☐Bites/Stings: ______. Reaction: ______.

☐Food(s): ______. Reaction: ______.

☐Nuts: ______. Reaction: ______.

☐Seasonal: ______. Reaction: ______.

☐Other: ______. Reaction: ______.

Additional Details of Allergies & Reactions:

Click here to enter text.

Dietary Restrictions:

Click here to enter text.

Please explain any limitations, activity restrictions or other concerns that might affect the volunteer’s participation in the camp program. Please note any other important or pertinent health-related information.

Click here to enter text.

Immunization Records (If under 18)

YOU MUST ATTACH A PHOTOCOPY OF YOUR IMMUNIZATION RECORD. IF YOU DO NOT HAVE ONE, YOU CAN OBTAIN A COPY FROM YOUR PHYSICIAN OR FROM YOUR SCHOOL. IF YOU DO NOT PROVIDE THIS INFORMATION, YOU WILL NOT BE ALLOWED TO ATTEND CAMP.

If you have any problems obtaining your immunization records please contact Mrs. Darlene Waldt as soon as possible so that we may assist you. (443-799-1009)

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PLEASE PRINT THIS PAGE (PAGE 10) AND SEND TO YOUR DOCTOR

Camp Opportunity Physician’s Standing Orders

Patient Name: Patient Date Of Birth:

PHYSICIAN: CHECK APPROVED TREATMENTS/MEDICATIONS

☐Pain or fever: Tylenol tabs (acetaminophen) 500 mg. 1-2 tabs every 4-6 hr. or acetaminophen liq.10-15mg/kg every 4-6 hr.

☐Inflammation / pain: Ibuprofen 200 mg.1-2 tabs every 4-6 hours or Children’s Ibuprofen Oral Suspension administered per package directions. Do not give if history of ulcer or other stomach problems. Discontinue use and see physician if black-colored stools.

☐Pain: Aspercreme or topical analgesic equivalent. Apply to affected area per package directions.

☐Mouth/tooth Pain: Orajel. Apply to affected area per package instructions.

☐Sore throat / Cough: Cough drop if unable to gargle with warm salt water.
Tussin DM cough syrup or equivalent as directed for non-diabetic. Not to be given to anyone under the age of 6 (six).

☐Nasal congestion: Sudafed PE 30 mg., Sudafed PE liquid or Claritin 10 mg. or equivalent of loratadine.

☐Abdominal distress: Maalox (liquid antacid) or Tums administered per package directions; do not use for more than 24-48 hours without consulting a physician

☐Form Diarrhea: Clear liquid diet; avoid dairy products X24 hrs. Bland diet first day after symptoms subside. If no response: Imodium (loperamide) or equivalent administered per package directions if no blood in stools and no fever. May hold routine prescribed bowel medication during episodes of loose stools.

☐Constipation: Day 2 with no BM: 8 oz. prune juice and/or 1 Tbsp Metamucil, at breakfast and supper, encourage fluids Day 3: continue giving prune juice and/or Metamucil; also give 30mL Milk of Magnesia, encourage fluids Day 4 (12-24 hours after MOM): Bisacodyl 10 mg suppository or equivalent, encourage fluids Day 5 (12 hours after suppository): Fleets enema, encourage fluids. If bowel sounds are absent or constipation continues after administration of an enema, contact M.D.

☐Itching due to insect bites or rash: Anti- itch lotion or gel or Hydrocortisone 1% cream (with application of cold compress for insect bites). Benadryl tabs (Diphenhydramine) or Liquid Benadryl or Claritin (loratadine) administered per package directions. May apply Meat Tenderizer paste for bee sting.

☐Anaphylaxis: EpiPen: Jr. and Adult dose Auto-Injector located in health center.
Personal supply to be carried with individual at all times.
After administration immediately dial 911 for emergency transport.

☐Athlete’s feet: Lotrimin cream or equivalent applied per package directions

☐Irritated eyes: Artificial Tears or lubricating eye drops instilled per package directions. May administer one dose of loratadine or equivalent.

☐Probable conjunctivitis: Flush affected eye with Artificial Tears and apply warm compress for 5-10min. Repeat as needed for comfort. If no improvement after 4hrs contact caregiver and advise to see MD.

☐Minor cuts and scrapes: cleanse with soap and water or half-strength Hydrogen Peroxide. Apply Bacitracin or equivalent, topically then apply dressing.

☐Chapped lips: Lip Balm or equivalent applied to topically per package directions

☐Mosquito/insect bite prevention: Mosquito Repellent cream/lotion to skin or spray to clothing per package directions

☐Sunburn prevention: Sunscreen SPF 15 or greater applied topically per package directions

☐Sunburn discomfort: Aloe gel applied to skin per package directions.

☐Dry skin: A & D Cream or moisturizing lotion applied topically as needed

☐Head Lice: Lice Free, Lice Sol Kit or equivalent used topically per package directions