London Volunteer Registration ESWO Purple Nation Summer Camp 2022

Epilepsy Southwestern Ontario is proud to present ESWO Purple Nation Summer Camp.

Purple Nation Summer Camp will run Thursdays from 8:30am to 4:30pm at two locations in or close to London, ON. Five camp days (July 21, 28, and August 11, 18, and 25) will be spent at Graham Family EcoPark located at 15769-, 16033 Medway Rd, Arva, ON N0M 1C0. The other three camp days (July 7, 14, and August 4) will be spent at the South London Neighbourhood Resource Center located at 1119 Jalna Blvd, London, ON N6E 3B3.

The first week of camp begins on July 7th and runs until August 25th. As a volunteer, we ask that you commit to at least 4 camp days.

Volunteers will be required to have mandatory seizure first aid training on a date TBD prior to camp. More details will be provided closer to the date.

Every volunteer must provide a vulnerable screening report (police check) before attending camp. ESWO can provide you with a letter stating that you are an active volunteer. With this letter, the police check will only cost $15.00. We will only accept volunteers who have a clear record check, which has been processed within the last year.

Volunteers must read and agree to the following...

I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending an Epilepsy Southwestern Ontario event and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at an Epilepsy Southwestern Ontario event may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Epilepsy Southwestern Ontario employees, volunteers, and program participants and their families.

Signature

Clear

Name *

First Name Last Name

E-mail *

Phone Number

Area Code Phone Number

I will attend training on:

I will attend training on .... I need to book an alternative training date

Emergency Contact *

Emergency Contact phone: *

Reference 1 Name *

Reference 1 Email *

Reference 2 Name *

Reference 2 Email *

Reference 3 Name *

Reference 3 Email *

Volunteers must have a current vulnerable sector police record check. Do you have a current police record check (within 1 year)? *

Yes I have applied, and am waiting I am under 18 years old, and do not need a record check. I have not applied yet

Volunteers must have proof of at least two doses of approved Health Canada COVID-19 vaccines, or proof of valid medical exemption. Do you have two doses of the COVID vaccine or an exemption? *

Yes I have two or more doses of the COVID-19 vaccines I have proof of medical exemption from the COVID-19 vaccines No, I do not have two or more doses of the COVID-19 vaccines and do not have a medical exemption

Volunteer T-Shirt Size:

Volunteer Medical Information

This information is voluntary, not mandatory. Please complete if there is anything above and beyond standard first aid protocol that you feel staff members should know about you.

Medical Information:

PHOTOGRAPH AND MEDIA CONSENT

Dear Volunteers,
During ESWO Purple Nation Summer Camp, staff will be taking pictures. Epilepsy Southwestern Ontario and our funding organizations are looking to use some of these pictures in advertisements, printouts and other publications to publicize our efforts towards inclusion.

If you give Epilepsy Southwestern Ontario and its funding organizations permission to use your pictures in their publications, please fill out the area below.

Photo Consent *

I understand, and I give consent for my photograph to be used by Epilepsy Southwestern Ontario and its funders. I understand, but do NOT give consent. I do not understand.

CONFIDENTIALITY AGREEMENT

All persons, staff and volunteers, who receive, through any means, information regarding a client or member as a result of their work with Epilepsy Southwestern Ontario are expected to maintain strict confidentiality concerning the business and affairs of Epilepsy Southwestern Ontario and its clients.

NO INFORMATION SHOULD BE DIVULGED UNLESS EXPRESSED AUTHORIZATION HAS BEEN RECEIVED FROM THE CLIENT AND THE EXECUTIVE DIRECTOR OF EPILEPSY SOUTHWESTERN ONTARIO.

Special care should be exercised even if the client’s name is not revealed, because it is often possible to identify a client by the unique facts of his or her case.

The duty of confidentiality exists, regardless of whether the relationship has been terminated. All persons in possession of confidential information should avoid indiscreet conversation even with one’s spouse or family. Furthermore, any gossip about such matters should be avoided at all times.

By signing below, you indicate that you have read the above statements and agree to comply with all of the above.

Dated: *

Confidentiality Agreement *

I understand, and I agree I understand, and I do NOT agree I do not understand.

VOLUNTEER CONTRACT

Upon agreeing to the roles and responsibilities of a volunteer for Epilepsy Southwestern Ontario, I agree to:

Always watch the participant that I have been assigned to. Always be aware of where my participant is, what they are doing and who they are with.
Ask for help if my participant is more then I can handle.
Put my participant ahead of my personal social life.
Report to my supervisors if my participant is experiencing an active medical issue.
Ensure that my participant is safe. (I have read my participant’s profile and I’m aware of their medical situation)
Encourage participants to engage in play with others (or myself) and try new things.
Respect my participant.
Be accountable: I will let my supervisors know ASAP if I cannot attend a day that I previously committed to attend.
NOT use any offensive language. (ie. profanities, sexual innuendoes, references to drinking, drugs, or sex.)
Leave my cell phone, iPod or MP3 player either at home, in my bag, or turned off during camp hours.
Dress appropriately (No “short shorts,” no low cut shirts, no underwear showing).

I have read the above statements and understand that if I neglect to fulfill my duties and responsibilities as stated, my supervisors, Michelle Franklin (CEO), Holly O'Neill and/or Rheannon Proctor may ask me to relinquish my role as a volunteer.

Volunteer Agreement *

I understand, and I agree I understand, and I do NOT agree I do not understand.

Thank you for completing this form. Training is mandatory for participation in all ESWO's children's programs. Once you have completed training, you are welcome to join us to volunteer, but you must sign up in advance. (Link to be posted)

For more information or for any questions, please contact Holly O'Neill at holly@epilepsyswo.ca

London Volunteer Registration ESWO Purple Nation Summer Camp, 2022