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/ Page 1 of 2 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 Page 2 of 2
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