Returning Volunteer Application

 Easterseals Southern California
401 S. Ivy Street
Escondido, CA 92025
Phone: 951-264-4855
To:
Easterseals Camp Staff and Friends
From: Amanda Showalter
Re:
Summer 2017
Fax: 760-406-6048
www.easterseals.com/southerncal.
Greetings to all! I hope this finds you feeling well and enjoying life.
Our 2017 summer Camp will take place at YMCA Camp Oakes. We hope you’ll be able to join
us for…
“Sci-Fi Camp - The Final Frontier!”
August 5-12, 2017
Please take a few minutes now and complete the attached Returning Staff Application.
Please note a couple of areas on the application:
Vegetarian – If you indicate that you are a vegetarian, you will be provided the
vegetarian items at each meal. We are trying to improve food service and reduce
waste and need an accurate count of vegetarians.
Scheduled Medications – The medical team is preparing files before camp. Please
assist them by completing your medication information accurately now so that
they do not need to spend time updating their files at camp unless you've had a
medication change.
Please submit the completed form by one of the following methods:
-
scan/email to [email protected] (preferred)
mail to: Easterseals Camp App, 4311 Klump Ave., Studio City, CA 91602
After your completed form is received, a member of the Directing Staff will contact you.
If you need another set of forms or if you have a friend who would like to volunteer as a new staff
person, both returning and new volunteer applications are available on the website. The Easterseals
website address is -- http://www.easterseals.com/southerncal/our-programs/camping-recreation/
Should you have any questions, please contact me at 951-264-4855 or by email at
[email protected].
I look forward to hearing from you, and I truly hope you can join us at camp!
EASTERSEALS / YMCA CAMP OAKES
AUGUST 5-12, 2017
RETURNING VOLUNTEER STAFF APPLICATION
Name__________________________________ Male ____ Female____ Age_______ Date Year _________
Email______________________________________ Alternate Email______________________________________
Cell_(_____)___________________ Home_(_____)__________________ Work_(_____)_____________________
Mailing address___________________________________City_________________State_______Zip____________
Emergency Contact________________________________ Relationship ____________ Phone_________________
Circle your most recent year at camp: 2016 2015 2014 2013
Volunteer position and/or Cabin #______________
If CPR, First Aid or lifeguard certified, please indicate certification(s) and expiration date(s)_____________________
Vegetarian:
Yes ______
No _______
HEALTH INFORMATION
Date of Last
Family Physician______________________________________ Phone_________________ Physical Exam_________
Medical Insurance
Carrier_____________________________________
Policy and/or
Group #_____________________________________________
Are you currently being treated for any chronic health condition? If yes, please list:
Has your doctor provided you with any restrictions from activities? If yes, please list.
If there are other activities that you feel you cannot complete due to your health condition please list here:
Allergies:
____ None known
____ Yes, Allergies to medication. Name medication and reaction:___________________________________________
____ Yes, Other allergies. Describe allergy and reaction:___________________________________________________
For all allergies, please list intervention (e.g., epi pen, inhaler, etc.)____________________________________________
If you require an epi pen or inhaler, please bring it to camp.
Scheduled Medications: (Oral Medications, Vitamins, Supplements: List ALL of the oral medications, vitamins, supplements you are currently
taking on a regular basis.) *Please bring these medications.
Drug Name
Bedtime
Strength/Concentration
Breakfast
Lunch
Dinner
Example Drug XYZ
1 pill =
mg
NA
2 pills
NA
1 pill
For questions about camp, contact Amanda Showalter at EasterVeals at 951.264.4855 or [email protected]
In an effort to go green and reduce costs, we will communicate via email.
If you or anyone you know would like to donate to camp, visit us at
http://www.easterseals.com/southerncal/our-programs/camping-recreation/
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VOLUNTEER AGREEMENT – STANDARDS OF CONDUCT
There is no possession or use of alcohol, marijuana, prescription drugs (except as prescribed and listed above) or non1.
prescription drugs (except those given by the infirmary), or any illegal substances while in camp. All laws are enforced.
2.
3.
4.
5.
6.
Personal relationships with other staff members are at all times proper for an EasterVeals/YMCA camp setting
and shall not interfere in working with the campers.
All relationships with campers shall be proper. Any case or suspicion of child abuse shall be reported to the
Directors immediately, and is grounds for dismissal from camp.
Each volunteer agrees to remain at YMCA Camp Oakes throughout the week unless leaving for an
Easterseals/YMCA camp sponsored activity.
Each volunteer performs all duties as set forth in the job description and volunteer responsibilities and as
assigned by the Directing staff.
Each volunteer follows all policies as identified in the Staff Manual.
ABUSE POLICY
Easterseals Southern California prohibits and does not tolerate abuse of any person or participant in its programs and
services, or on any premises under its supervision. Abuse is defined as including physical abuse, physical neglect, sexual
abuse or molestation, financial abuse, child neglect, and/or emotional abuse. Employees, volunteers, and staff of
Easterseals Southern California will comply with the law and this policy by reporting suspected abuse to management staff and
other authorities. If any volunteer is accused of abuse, he or she will immediately be removed from contact with campers
pending the outcome of the investigation and either Adult, or Child, Protective Services will be notified. Easterseals is
committed to raising consciousness of consumers and their families regarding abuse and their right to report suspected
instances of abuse.
MEDICAL AND MEDIA CONSENT
I hereby certify that the individual on this application is in good health and capable of participating in and using the camp
program and equipment and facilities. I hold Easterseals and YMCA of Greater Long Beach harmless for any damages
or injuries sustained in any activities. I understand that I must comply with the camp rules and standards for participant
behavior. I agree that Easterseals and the YMCA have the right to enforce appropriate standards of conduct and that the
organizations may terminate my participation in the camp program if I do not maintain these standards. Further, I give my
consent for the use of my comments and photographs to be used in promotional materials for Easterseals and the
YMCA. This Health Information is correct to the best of my knowledge and I am able to engage in all prescribed camp
activities, except as noted on this application form. I hereby authorize Easterseals and the YMCA and its delegated
leaders and directors to consent to any medical and hospital care, (which may include but not be limited to x-rays,
anesthesia, surgery, hospital care and dental work), to be rendered upon the advice of a licensed physician or dentist.
This authorization is given pursuant to the provisions of the California Medical Practice Act. It is understood that if time
and circumstances reasonably permit, Easterseals and the YMCA will endeavor, but are not required, to communicate
with me prior to such treatment. I further agree that Easterseals and the YMCA and designated leaders and directors are
not responsible for costs incurred for medical care or for any claim arising from any consent given in good faith in
connection with such diagnosis or advised treatment. This authorization and consent to treatment is given to Easterseals
and the YMCA in conjunction with any authorized event.
I hereby find the above rules acceptable and understand that I must not abuse any person as described in the above
policy and that I am required to report any abuse which I suspect has occurred.
As a volunteer for Easterseals/YMCA Camp Oakes, I will do everything in my power to make a fun and safe camp
for all involved, especially the campers. I understand that my participation in the camp runs from Saturday, 1:00
pm on August 5, 2017 through Saturday, 1:00 pm on August 12, 2017.
I declare that the information provided in this application is true and complete. If accepted for a position, any
misstatement or omission of fact on this application may result in my dismissal. You are hereby authorized to make any
investigation of my personal history through any investigative service of your choice. I understand that this is a voluntary
position and that I will not receive a salary or wage.
________________________________
Print Name
___________________________________
Signature
___________________________________________
Parent/Guardian Signature (if applicant is under age 18)
________________
Date
By my signature I grant permission for this minor to participate
as a volunteer staff person for Easterseals.
Please scan/email your completed application (2 pages) to [email protected]
If you are not able to email the application, please mail it to:
Easterseals Camp App, 4311 Klump Ave; Studio Ciy, CA 91602
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