Camp Jamie Volunteer Application

CAMP JAMIE VOLUNTEER APPLICATION
Today's date*

MonthDayYear
Date
Date of camp

MonthDayYear
Date
All information is strictly confidential
NAME*
Address*
County
How long have you lived at this address?*
If less than a year, please give previous address
Home phone*
Cell phone
Please enter a valid phone number.
Email*
example@example.com
Birthdate*

MonthDayYear
Date
Age
Gender
Ethnic background (Optional)
Education
High school attended
Year completed
College attended
Year completed
Degree

Employment
Current line of work:
1. Place of employement
Dates of employment

MonthDayYear
Date
2. Place of employment
Dates of employment

MonthDayYear
Date
3. Place of employment
Dates of employment

MonthDayYear
Date

Volunteer Experience
Agency or Organization
Do you have any physical limitations?

YesNo
If yes, please explain
Are you available for the entire weekend (approximately Friday 3:00pm to Sunday 1:00pm)

YesNo
Are you authorizing Frederick Health Hospice to conduct a background check?

YesNo
Loss History:
Relationship: Year of death:    Age of diseased:      Cause of death:

Relationship:    Year of death:      Age of diseased:      Cause of death:

Relationship:      Year of death:      Age of diseased:      Cause of death:

Relationship:      Year of death:      Age of diseased:      Cause of death:

Relationship:      Year of death:      Age of diseased:      Cause of death:

Relationship:      Year of death:      Age of diseased:      Cause of death:

Camp Jamie Volunteer Application
What position would you like to hold at Camp Jamie?

Big buddySupport staff
Big Buddy

You are paired with a camper of the same sex. You will spend the entire weekend side by side with this little buddy, including sleeping arrangements. You provide companionship, support, friendship, and individualized attention to your little buddy. We do our best to pair little and big buddies that we think are the best possible fit for each other.

Support Staff

You help bereavement counselors and staff set up and cleanup activities and crafts. You will provide any help or support to a big buddy, and act as an escort to big buddies and little buddies in certain situations. All support staff are in charge of one group activity so the big buddies get a break.
Have you ever been a volunteer at Camp Jamie?

YesNo
If yes, in what capacity?
Specify the age range you are most comfortable working with blank .
Are you comfortable working with any type of loss?*

YesNo
Our campers have experienced a wide range of losses to include; suicide, homicide, accidents, overdose, illnesses. While we do our best to be sensitive to your level of comfort working with children of certain ages or grieving certain losses, we cannot always accommodate your preference. List any type of loss you are uncomfortable with.
List any type of loss you are uncomfortable with.*
Please list any experience you have working with kids.*
Do you have experience at any other children's camps?*

YesNo
If yes, when & where?
Why do you wish to volunteer at Camp Jamie?*
T-Shirt Size*

CAMP JAMIE VOLUNTEER APPLICATION

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT
Should a medical emergency arise during my participation in Camp Jamie activity and I am unable to speak for myself, I consent to:

1. The administration of medical treatment and/or surgical procedures deemed necessary by the medical doctor and/or medical facility identified below or chosen by the Camp Jamie Director and

2. The immediate administration of life-sustaining measures deemed necessary under the circumstances.
Signature*

Clear
Date

MonthDayYear
Date
Preferred medical doctor/facility
Address
Telephone Number
Insurance Company
Policy Number
Policyholder's Name

CAMP JAMIE VOLUNTEER APPLICATION

STATEMENT OF CONFIDENTIALITY
I understand that information regarding Frederick Health Hospice patients, their families and/or significant others, and any persons receiving support or services in any capacity is privileged information for use by and with authorized persons only.

Iwill disclose such information only in the discharge of my assigned duties and responsibilities

with Hospice or persons authorized to receive such information through the signed consent of patient, family member, or affected party.

I will not disclose any information with anyone unauthorized to receive this information. I will handle any and all paperwork and forms with proper procedure of control so that no information is accidentally observed or released to any unauthorized persons. I also understand that the casual sharing of patient care information in public places or settings is inappropriate.

I further understand and agree that any violation of this policy is of such critical offense that it will justify my immediate discharge.
Print Name
Signature*

Clear
Date

MonthDayYear
Date

CAMP JAMIE VOLUNTEER APPLICATION

VOLUNTEER RELEASE OF LIABILITY
I understand and agree that Frederick Health Hospice, Board of Directors, Employees and Volunteers are released from any legal responsibility and/or liability for negligence arising out of any accidents or illnesses which occur while the volunteer listed below attends Camp Jamie.
Signature of Volunteer*

Clear
Date

MonthDayYear
Date
VOLUNTEER PUBLICITY PERMISSION
Upon occasion, videotaping and/or photography may occur during camp activities. This material may be used for future publicity by Frederick Health Hospice and its Board of Directors. In addition, with Hospice staff permission and supervision, the news media may wish to photograph, videotape and/or interview some of the volunteers and children attending camp. Please sign below if you have no objections to being subject to this.
Signature of Volunteer*

Clear
Date

MonthDayYear
Date
BACKGROUND CHECK CONSENT
I understand and consent that Frederick Health Hospice will conduct a background check through HireRight as a part of my application to be a Camp Jamie volunteer.
Signature of Volunteer*

Clear
Date

MonthDayYear
Date

CAMP JAMIE VOLUNTEER APPLICATION

REFERENCES
Please list the names, addresses and phone numbers of 3 references, 2 of which can be personal references, 1 being a present or former supervisor
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
In which capacity and how long have you known this person?
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
TELEPHONE NUMBER
In which capacity and how long have you known this person?
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
TELEPHONE NUMBER
In which capacity and how long have you known this person?

Should be Empty:

CAMP JAMIE VOLUNTEER APPLICATION

Education

Employment

Volunteer Experience

Camp Jamie Volunteer Application

Camp Jamie Volunteer Application

CAMP JAMIE VOLUNTEER APPLICATION

CAMP JAMIE VOLUNTEER APPLICATION

CAMP JAMIE VOLUNTEER APPLICATION

VOLUNTEER PUBLICITY PERMISSION

BACKGROUND CHECK CONSENT

CAMP JAMIE VOLUNTEER APPLICATION