CAMP PHOENIX
MANITOBA FIREFIGHTERS BURN FUND
March 2017
Dear Potential Camp Volunteer:
Hello! We’re heading back to Moose Lake Camp! For those of you who are new volunteers, you should know
that Camp Phoenix is funded by the Firefighters Burn Fund and is for children aged 6 to 17 who have been
patients in the Children’s Hospital Burn Unit. The dates for this year’s camp are July 24 to 27, 2017, and
takes place at Moose Lake Camp located in Southeastern Manitoba. We will be starting off on
Monday, July 24th at 11:00 a.m. at Fire station #1 on Ellen St., where the campers, their families and
volunteers will have a kick-off BBQ. Then it is off to Moose Lake at 12:30 p.m. We will return to the Health
Science Centre after camp and anticipate arriving back at about 3:15 p.m. on Thursday July 27th.
If you would like to volunteer for this year’s camp, please return the following by June 1, 2017 to the
address or fax listed above, your package must include:
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Completed Volunteer Application Form
2 Completed Reference Forms (New applicants only)
Completed Child Abuse Registry Form
Criminal Record Check Receipt*, or a copy of Criminal Record check that is no more than
one year old for new volunteers, or 2 years old for returning volunteers.
Momenta waiver
*Criminal record checks must be completed by all volunteers. If you would like to be reimbursed for
your criminal record check, please include your receipt with your application form, we will reimburse
you for the full amount by cheque once your receipt has been received.
Registered volunteers will be contacted by phone the week of June 12, 2017 to confirm your
attendance.
We have planned a pre-camp orientation night on July 4th, 2017 at 6:00 pm at the Momenta office (984
Portage Ave – entrance is on Aubrey). Returning and new volunteers must attend the orientation. If
you cannot commit to both camp and the orientation, please do not apply. Pizza and refreshments will
follow the orientation.
Thank you once again for your interest in Camp Phoenix! Please do not hesitate to contact me if there are
any questions. If you would like to be removed from our mailing list, please send an email to Krista Law,
[email protected]
Sincerely,
Krista Law
Camp Registrar
[email protected]
Camp Phoenix VOLUNTEER APPLICATION FORM
Name: ______________________________________________ Email: _______________________________
Address: __________________________________________________
Home phone: ___________________
City: _______________________ Province: ______________________
Work phone: ___________________
Postal Code: ________________ Birthdate: ______________________ Gender/Pronoun: _______________________
Do you have any allergies, dietary needs or medical conditions we should be aware of ?
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
______________________________________
Family doctor: _____________________________________________
Phone: ________________________
Manitoba Medical number: ___________________________________________________________________
In case of an emergency, please contact: (list name, relationship and phone number)
______________________________________________________________________________________
______________________________________________________________________________________
Questions 1 to 4 are for NEW volunteers only:
1. How did you hear about Camp Phoenix?__________________________________________________
2. Why are you interested in being a volunteer at Camp Phoenix?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
3. List any experience you have working with children. Please specify any experience working with children
who have a disfigurement or a disability.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
4. Please list two references and either attach completed forms or have references send/fax them in. Please do
not use relatives – employment or academic references preferred.
_________________________________________________________________________________________
_________________________________________________________________________________________
Questions 5 to 10 are for ALL volunteers:
5. What age group do you prefer working with? (Efforts will be made to place volunteers with their preferred
age group, although this cannot be guaranteed)
Ages 6-9 _____
Ages 10-13 _____
Ages 14-16 _____
6. Are you available for the whole camp session? (July 24 @ 11:00 a.m. – July 27@ 5:00 pm)
Yes _____ No _____
If no, when are you available? ______________________________
7. List any special interests or talents that may enhance our camp.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
8.
Have you ever been convicted of a crime involving mistreatment of a minor or violence against a person of
any age?
Yes _____
No _____
* I certify that the information provided in this application is, to the best of my knowledge, true, correct
and as complete as possible.
__________________________________________________________
Signature
___________________
Date
Application Checklist:
☐Completed Application Form
☐Criminal Record Check or Receipt Showing it has been Submitted
☐Completed Child Abuse Registry form
☐Two References if you are a NEW volunteer only (these can be faxed to 204-415-4327 by your references)
Camp Phoenix REFERENCE FORM
Applicant to complete this section:
I _________________________________________ give permission for the below named reference to
(Volunteer Applicant’s name)
provide information to Camp Mamawi to be used for the purposes of selecting volunteers for the
annual burn camp.
_________________________________
(Volunteer Applicant’s signature)
Reference to complete this section:
The above named individual is an applicant for a volunteer position at Camp Phoenix. We would
appreciate your frank appraisal of this person. Please feel free to add any comments or information
that you feel would assist in the applicant’s evaluation.
1.
How long have you known the applicant? _________________________________
In what capacity? (i.e. friend, employer, co-worker) _________________________
2.
Please rate the applicant by placing a check mark beside the appropriate description:
Displays a positive attitude
Yes ____ No ____ Have not observed ____
Relates well with peers
Yes ____ No ____ Have not observed ____
Works well as part of a team
Yes ____ No ____ Have not observed ____
Handles responsibility well
Yes ____ No ____ Have not observed ____
Appears emotionally stable
Yes ____ No ____ Have not observed ____
Displays sensitivity of the needs of children Yes ____ No ____ Have not observed ____
3.
Why would you recommend this individual as a volunteer at a children’s camp?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
4.
Do you have any reason to question this person’s suitability for working with vulnerable
children?
Yes ____ No ____ If yes, please explain.
_____________________________________________________________________________
Name: ______________________________ Title: _______________________________
Address: ____________________________ Phone number: _______________________
Signature: ____________________________________
Thank-you for your assistance. Please return by June 13th, 2014 to Lise Brown at the address listed below:
Program_____________________
Date_____________________
WAIVER AND RELEASE OF LIABILITY
In consideration of being allowed to participate in any way in Momenta experience discover grow’s
athletic/sports program, related events and activities, the undersigned acknowledges, appreciates, and
agrees that:
The risk of injury from the activities involved in this program is significant, including the potential for permanent
paralysis and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious
injury does exist; and,
I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown physical and legal,
EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full
responsibility for my participation. I knowingly waive my right to bring any legal action for any injuries I may suffer as a
result of my participation in the above activity; and,
I willingly agree to comply with the stated and customary terms and conditions for participation. If however I observe any
unusual significant hazard during my presence or participation, I will remove myself from
participation and bring such to the attention of the nearest official immediately; and
I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY
RELEASE AND HOLD HARMLESS Momenta experience discover grow their officers, officials, agents
and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of
premises used to conduct the event ("Releasees"), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or
loss or damage to person or property, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR
OTHERWISE.
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY
SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
_____________________________
PARTICIPANT NAME
______________________________
PARTICIPANT'S SIGNATURE
_____________
DATE SIGNED
_____________________________
WITNESS NAME
______________________________
WITNESS’S SIGNATURE
_____________
DATE SIGNED
FOR PARTICIPANTS OF MINORITY AGE (UNDER AGE 18 AT TIME OF REGISTRATION)
This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her
release as provided above of all the Releasees, and, for myself, my heirs, assigns, and next of kin, I release and agree to
indemnify the Releasees from any and all liabilities incident to my minor child's involvement or participation in these
programs as provided above.
_____________________________
PARENT/GUARDIAN NAME
______________________________
PARENT/GUARDIAN SIGNATURE
_____________
DATE SIGNED
_____________________________
WITNESS NAME
______________________________
WITNESS’S SIGNATURE
_____________
DATE SIGNED