Camp Crescent Moon 2023 Medical Team

Medical Team Application

Camp Dates - July 15-22, 2023
Up-to-date Covid-19 vaccination is required for all attendees

You are up-to-date with your COVID-19 vaccines when you have received all the recommended doses in the primary series and the most recent booster dose recommended for you by CDC. If you have completed your primary series, but are not yet eligible for a booster, you are also considered up to date. But when you become eligible for a booster dose, you are no longer up to date until you get that dose.
Thank you for being so interested in volunteering for Camp Crescent Moon.

Please be prepared to upload the following items with the application.

1. Copy of professional license (if applicable)

2. Proof of Covid-19 vaccination & booster

3. Copy of Government Issued ID (first-time volunteers)
Name*

First NameLast Name
Email*

Confirmation Emailexample@example.com
Phone Number*
Please enter a valid phone number.
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Profession (check all that apply)*

MD/DONPRNLVNRN Student (limited availability)LVN Student (limited availability)Social Worker (BSW/MSW/LCSW)PsychologistPAOther
Specialty (select all that apply)*

PediatricsAdultsTeensOther
License # (if applicable)
State licensed (if applicable)
Please upload copy of medical/professional license:

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Please upload proof of Covid-19 vaccination & booster*

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Have you volunteered as a Medical Provider at Camp Crescent Moon before?*
FIRST-TIME VOLUNTEERS - Please upload copy of your government issued identification with a photo (Driver's license, ID card, Passport)

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Employer (or school if applicable)
Department
Address (Employer or School)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact*

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.
Emergency Contact Relationship*
Are you available to volunteer for the entire camp week? Dates are July 15-22, 2023 (this is Saturday to Saturday)*
If no, please select days of availability (shift time is approximately 9:00 am - 9:00 pm)*

Saturday, July 15thSunday, July 16thMonday, July 17thTuesday, July 18thWednesday, July 19thThursday, July 20thFriday, July 21stOther
Dietary Preference (we may not be able to accommodate vegan only options)*
What is your T-shirt size?*
Comments
Have you ever been convicted of a criminal offense?*
Have you ever been charged with child abuse or neglect?*
Has your driver's license ever been suspended or revoked?*
Please explain if you answered yes to any of the above questions.
Other than the above questions, is there any fact or circumstance involving you or your background that may call into question your working with children? If yes, please explain:*
Upon submission of this application, you will receive the following documents via email for completion:
1. Applicant Release & Authorization (for background check)
2. Medical History Form
3. Immunization Update (PPD, Tetanus & Hepatitis B)
Thank you for your interest in volunteering at Camp Crescent Moon.

We will follow up with you shortly.
Should be Empty:

Medical Team Application

Up-to-date Covid-19 vaccination is required for all attendees