Camp Reynal 2024

It will approximately take 15 minutes to complete the application. You will not be able to save your work mid-way through the application, so please have the following information available prior to starting the application process:

All applicants:

• Upload a photo of your driver's license/state ID
• Medical insurance information

​Nurses:

• Upload a photo of your CPR Card

Physicians:

• Upload a picture of your Medical license
• Upload a picture of your Liability insurance

Thank you for understanding our need to be thorough for your protection, for the protection of the campers, and for the protection of Camp Reynal and the National Kidney Foundation

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General Information

Employment Information

Military

Education

Background Information

Medical

Insurance

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CONDITIONS IF ACCEPTED AS A CAMP REYNAL VOLUNTEER MEMBER, I UNDERSTAND:

1. The National Kidney Foundation and Camp Reynal accepts no responsibility for the loss, damage or theft of property.

2. Should your emergency contact, during the camp session, leave his/her place of residence, you will advise the camp administration where he/she can be contacted in case of emergency.

3. In case of medical and or surgical emergency, I authorize Camp Reynal medical staff to render to me or to arrange for me to receive any x-rays, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care which are deemed necessary.

4. I agree to arrive at camp at the specified time, unless an exception has been made prior to camp with the Counselor Coordinator.

5. I agree to report any accident or injury at the time of the incident.

6. All information regarding campers, counselors and staff is highly confidential and shall be protected and safeguarded by me.

7. I agree to maintain and provide evidence of health insurance coverage that will cover any injury that I may suffer while at Camp Reynal. I understand that I am not entitled to receive worker’s compensation benefits for such injuries.

8. I agree to carry out my assigned responsibilities with the camp, and to insure the physical and emotional well-being of the campers.

9. I, the undersigned, have represented and do represent that I hereby agree to indemnify and hold harmless, Children's Medical Center of Dallas, Cook Children's Medical Center, Christus Santa Rosa Children’s Hospital, North Texas Hospital for Children at Medical City Dallas, Camp Reynal and the National Kidney Foundation, and Camp John Marc, and the officers, directors, agents, contractors or employees of any of them collectively referred to as (the “Indemnified Parties”) for any and all liability of whatsoever nature (i) growing out or resulting from any injury to, sickness of, and /or damage to the undersigned relating in any way to my presence at, or use of facilities, or participation in the activities of, Camp Reynal and the National Kidney Foundation and Camp John Marc. I further release and waive any and all claims for damages against the Indemnified Parties that I may have or may hereafter acquire due to the use of, or my presence at, the facilities of Camp Reynal and the National Kidney Foundation and Camp John Marc. The foregoing also applies to the activities related to horses, canoeing and any other off-campground activity planned in accordance with Camp Reynal.

10. I agree that my status as a Camp Reynal member does not, in and of itself, create any employee relationship between myself and the National Kidney Foundation, Children's Medical Center of Dallas, Cook Children's Medical Center, Christus Santa Rosa Children’s Hospital, North Texas Hospital for Children at Medical City Dallas, Camp Reynal, and Camp John Marc, and their officers, directors, agents, or contractors.

11. I also hereby consent to the release of photographs and information pertinent to my stay at Camp Reynal at Camp John Marc.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

LIABILITY WAIVER
 
By attending or organizing this event and signing this form, I expressly warrant that:

• I will indemnify and hold the National Kidney Foundation (NKF) harmless from any and all claims of any kind or nature whatsoever arising out of, or in any way related to, this fundraising initiative.
• I acknowledge an inherent risk of exposure to COVID-19 exists in any public place where people are present. COVID-19 is an extremely contagious disease that can lead to severe illness and death. According to the Centers for Disease Control and Prevention, people with underlying medical conditions and older adults are especially vulnerable.
• I will indemnify and hold the NKF harmless from any and all claims of any kind or nature whatsoever arising out of, or in any way related to an alleged exposure to, or contracting of, COVID-19 by any attendee who alleges such exposure or illness during or after the Event.
• I voluntarily assume all risks related to exposure to COVID-19.
• If applicable, I also give permission for the free use of my name and picture in any media or other account of these events.

In consideration for being permitted to organize or participate in this event, I, the undersigned, waive and release NKF and its directors, officers, administrators, representatives and executors, employees, volunteers, agents, supervisors (collectively, the “Releasees”), from any and all claims, liabilities, or causes of action arising out of an injury to me, loss articles, loss of articles in car, car damage and car theft and from any and all claims, liabilities, or causes of action arising from my participation or attendance in this event. I voluntarily agree for myself, my family, heirs, assignees the following:

1. To assume full responsibility for any risks of loss, or personal injury, including death that may be sustained by me, or any loss or damage to property owned by me, as a result of participating in the event, including getting sick with COVID‐19 or any other communicable diseases.
2. To release, waive, hold harmless, discharge, and covenant not to sue the Releasees from any and all liability, claims, actions, demands, expenses, attorney fees, breach of contract actions, breach of statutory duty or other duty of care, warranty, strict liability actions, and causes of action whatsoever, that I might have or may acquire in the future, arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me, while participating in the Event including, but not limited to, any claim that the act or omission complained of was in whole or in part by the negligence or carelessness of the Releasees.

VOLUNTARY DISCLOSURE STATEMENT

Have you ever been charged or convicted of any crime of violence, including but not limited to those listed below?

I understand that:

The camp may deny the application of any person who answers any of the questions above in the affirmative.

In applying for a camp position, the information that I have furnished on this form is subject to verification, which will include a criminal history check and request from any central registry of child abusers.

The camp may terminate employment or voluntary service of any person:

• Found to have a history of complaints of abuse; and/or 
• Found to have resigned, been terminated, or been asked to resign from a position, whether paid or unpaid, due to complaint(s) of sexual abuse.

This disclosure statement must be updated on an annual basis.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

EMPLOYEE/VOLUNTEER CONFIDENTIALITY AGREEMENT

I, {name5}, have read and understand the Camp Reynal policies regarding the privacy, use, protection, and disclosure of Protected Health Information. I acknowledge that I have received training and education about, and understand, the requirements of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and its interpretative regulations regarding the use, protection, disclosure, and destruction of Protected Health Information.

In consideration of my participation as a volunteer or other staff member in the activities of Camp Reynal, I hereby agree that I will not at any time- either during my association with Camp Reynal and/or the National Kidney Foundation, or after this association ends-use, access or disclose Protected Health Information to any person internally or externally except as permitted and required in the course of my duties for Camp Reynal and only as permitted by HIPAA and the otherwise applicable provisions of law. I understand that this obligation extends to any Protected Health Information mat I may create or acquire during the course of my participation or involvement with Camp Reynal in the delivery of health care as a health care provider or other health care components of its or the National Kidney Foundation’s operations, whether in oral, written or electronic form.

I understand and acknowledge my responsibility to apply and comply with the policies and procedures of Camp Reynal and the National Kidney Foundation while participating in Camp Reynal as a volunteer or otherwise. I also understand that unauthorized use or disclosure of Protected Health Information will result in disciplinary action, up to and including termination of my involvement as a staff person or other volunteer, and the imposition of civil or criminal penalties under applicable federal and state law, as well as professional disciplinary action as appropriate.
I understand that this obligation will survive the termination of my involvement or association with Camp Reynal and/or the National Kidney Foundation, regardless of the reason for such termination.

 

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

EMPLOYEE AND VOLUNTEER APPLICANT BACKGROUND CHECK DISCLOSURE & CONSENT FORM

As an individual providing or applying to provide services as an employee, consultant, independent contractor, volunteer or other capacity, with National Kidney Foundation dba Camp Reynal, you are advised that National Kidney Foundation dba Camp Reynal, Inc. (the "Camp") may contact the Social Security Administration, another governmental agency or other parties directly or through a third party to verify the Social Security Number and certain other information as part of its verification of your eligibility and suitability to provide services as an employee, consultant, independent contractor, volunteer or in any other capacity.

In addition, the Camp may obtain a consumer report or otherwise check other background information about you to confirm your identity and eligibility for employment or for other employment or business purposes.

The Camp may also obtain a reference check on you for purposes of determining your suitability to perform services or serve in some other capacity, as we deem appropriate, in our exclusive discretion. The reference check, also referred to as an investigative consumer report, may include information about your character, general reputation, personal characteristics, identity, eligibility for employment in the United States, mode of living, criminal background, and other matters that we deem relevant to your eligibility and suitability for employment with the Camp.

As a condition of the Camp's consideration of you for prospective or continued eligibility to provide services as an employee, consultant, independent contractor, volunteer, or other capacity, the Camp requires that you give us written authorization to conduct this investigation including obtaining a background report on you (specifically, a consumer report and/or an investigative consumer report).

If the Camp elects to secure an investigation report, the Fair Credit Reporting Act may, under certain circumstances, provide you with the right to request, in writing within a reasonable amount of time, a disclosure of the nature and the scope of the investigative report. If required to comply with the Fair Credit Reporting Act, the disclosure shall be made in writing and mailed, or otherwise delivered to you no later than 5 days after the date on which your request is received or 5 days after the date on which the report was first requested, whichever is later. You may also request a Summary of Your Consumer Rights under the Fair Credit Reporting Act as prepared by the Federal Trade Commission. These can be obtained at no charge.

To obtain a disclosure of the nature and the scope of the investigative report about you, if any, run by the Camp, please provide us a written request. To obtain a Summary of Your Consumer Rights, simply let us know in your letter that you would like a copy.

I acknowledge that I have received this disclosure and I authorize the Camp and its affiliates, agents, successors and assigns to conduct an investigative consumer report and criminal background check for employment, volunteer, consulting, independent contractor or other purposes and consent to allow the Camp to contact the Social Security Administration or other governmental agencies to verify my Social Security Number and any other information that it deems relevant to verify my eligibility and suitability to provide or continue to provide services as an employee, volunteer, contractor or other capacity for the Camp.

I also understand that as long as I remain an employee, independent contractor, consultant, or volunteer for the Camp, the criminal history records check may be repeated at any time. I understand that I will have an opportunity to review the criminal history as received and a procedure is available for clarification, if I dispute the record as received. I also understand that the criminal history could contain information presumed to be expunged.

I, the undersigned, do, for myself, my heirs, executors and administrators, hereby remise, release and forever discharge and agree to indemnify the National Kidney Foundation and the related state or federal agencies and each of their officers, directors, employees and agents and hold them harmless from and against any and all causes of actions, suits, liabilities, costs, debts and sums of money, claims and demands whatsoever (including claims for negligence, gross negligence, and/or strict liability of the National Kidney Foundation of North Texas and the related state or federal agencies and any and all related attorneys’ fees, court costs and other expenses resulting from the investigation of my background in connection with my application to become a volunteer/staff member.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT

 

The federal Fair Credit Reporting Act (FCRA) is designed to promote accuracy, fairness, and privacy of information in the files of every "consumer reporting agency" (CRA). Most CRAs are credit bureaus that gather and sell information about you -- such as if you pay your bills on time or have filed bankruptcy -- to creditors, employers, landlords, and other businesses. You can find the complete text of the FCRA, 15 U.S.C. §§168l and following 168u, at the Federal Trade Commission's web site (http://www.ftc.gov). The FCRA gives you specific rights, as outlined below. You may have additional rights under state law. You may contact a state or local consumer protection agency or a state attorney general to learn those rights.

You must be told if information in your file has been used against you. Anyone who uses information from a CRA to take action against you -- such as denying an application for credit, insurance, or employment -- must tell you, and give you the name, address, and phone number of the CRA that provided the consumer report.

You can find out what is in your file. At your request, a CRA must give you the information in your file, and a list of everyone who has requested it recently. There is no charge for the report if a person has taken action against you because of information supplied by the CRA, if you request the report within 60 days of receiving notice of the action. You also are entitled to one free report every twelve months upon request if you certify that (1) you are unemployed and plan to seek employment within 60 days, (2) you are on welfare, or (3) your report is inaccurate due to fraud. Otherwise, a CRA may charge you up to eight dollars.

You can dispute inaccurate information with the CRA. If you tell a CRA that your file contains inaccurate information, the CRA must investigate the items (usually within 30 days) by presenting to its information source all relevant evidence you submit, unless your dispute is frivolous. The source must review your evidence and report its findings to the CRA. (The source also must advise national CRAs -- to which it has provided the data -- of any error.) The CRA must give you a written report of the investigation, and a copy of your report if the investigation results in any change. If the CRA's investigation does not resolve the dispute, you may add a brief statement to your file. The CRA must normally include a summary of your statement in future reports. If an item is deleted or a dispute statement is filed, you may ask that anyone who has recently received your report be notified of the change.

Inaccurate information must be corrected or deleted. A CRA must remove or correct inaccurate or unverified information from its files, usually within 30 days after you dispute it. However, the CRA is not required to remove accurate data from your file unless it is outdated (as described below) or cannot be verified. If your dispute results in any change to your report, the CRA cannot reinsert into your file a disputed item unless the information source verifies its accuracy and completeness. In addition, the CRA must give you a written notice telling you it has reinserted the item. The notice must include the name, address and phone number of the information source.

You can dispute inaccurate items with the source of the information. If you tell anyone -- such as a creditor who reports to a CRA -- that you dispute an item, they may not then report the information to a CRA without including a notice of your dispute. In addition, once you've notified the source of the error in writing, it may not continue to report the information if it is, in fact, an error.
Outdated information may not be reported. In most cases, a CRA may not report negative information that is more than seven years old; ten years for bankruptcies.

Access to your file is limited. A CRA may provide information about you only to people with a need recognized by the FCRA -- usually to consider an application with a creditor, insurer, employer, landlord, or other business.
Your consent is required for reports that are provided to employers, or reports that contact medical information. A CRA may not give out information about you to your employer, or prospective employer, without your written consent. A CRA may not report medical information about you to creditors, insurers, or employers without your permission.

You may choose to exclude your name from CRA lists for unsolicited credit and insurance offers. Creditors and insurers may use file information as the basis for sending you unsolicited offers of credit or insurance. Such offers must include a toll-free phone number for you to call if you want your name and address removed from future lists. If you call, you must be kept off the lists for two years. If you request, complete, and return the CRA form provided for this purpose, you must be taken off the lists indefinitely.

You may seek damages from violators. If a CRA, users or (in some cases) a provider of CRA data, violates the FCRA, you may sue them in state or federal court.