Civitan's Camp Big Heart 2024 Nursing Application

Civitan's Camp Big Heart 2024 Nursing Application
If you have any questions about this form or working at camp, please feel free to reach out to Ethan Erlandson at ethan.erlandson1@gmail.com or 941-962-8105.
Identifying and Contact Information
Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail is one of the main ways we will contact you. Please list an e-mail account that you will check regularly between now and camp.
E-mail*
example@example.com
Phone Number*
Alternate Phone Number
Your picture file must be named Firstname_Lastname
Recent Photo*

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T-Shirt Size (shirts are in mens sizes)*

SmallMediumLargeX-LargeXX-LargeXXX-Large
Desired Position
Desired Position*
Desired Session(s) Choose all that apply*

SESSION 1: June 8 – June 14, 2024 (Adult Aged Campers (18 and older))SESSION 2: June 15 - June 21, 2024 (School Aged Campers)
Have you worked at Camp Big Heart before?*

YesNo
How many years, and in what positions?
Who were your previous unit leaders & volunteers or nursing staff?
Emergency Contact
Full Name*

First NameLast Name
Phone Number*
Relationship*
If this is your first time at camp, fill out the following sections.
Describe any WORK experience you have had including employer, position, and dates of employment.
Describe any CAMP experience you have had including employer, position, and dates of employment.
Describe any experience you have working or interacting with members of the special needs community.
Provide a non-family member reference below for us to contact. This can be a teacher, coach, mentor, or previous employer.
Full Name

First NameLast Name
Relationship
Time Known
E-mail
example@example.com
Phone Number
Certifications and Skills
What is your license number?*
May we look you up in the GA board of Nursing data base? If not, why?*
Medical Information
Please list any allergies you have.
Are you a vegetarian who requires vegetarian meals?*

YesNo
Describe any other dietary restrictions you have.
Medical History (check all that apply)

Seizure DisorderActive SeizuresDiabetesHeart Problems
Please list any other health conditions that may limit your ability to perform your duties at Camp Big Heart.
Medical Insurance

MANDATORY- You must upload a copy of your insurance card (front and back) to complete your application. If you currently do not have health insurance, please write N/A in the boxes below.
Insurance Company*
Contact Number*
The picture files you upload for your insurance must be named Firstname_Lastname_Front and Firstname_Lastname_Back. This naming convention must be followed to insure your application is processed.
Insurance Card (Front)*

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Insurance Card (Back)*

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How did you hear about Camp Big Heart?*
Photo Release

"I agree to allow photography of the applicant to be used by the Camp Big Heart and/or Camp John Hope for any publicity and/or promotional and/or educational purposes including leaflets, flyers, brochures, television, newspapers, magazines, advertisements, audio-visuals, videos, etc. which further the aims of Civitan’s Camp Big Heart to provide a summer recreational camp for our campers who are mentally challenged at a low cost to the participants, the majority of costs of said camp being underwritten by the Camp Big Heart Civitan Club."
I have read and agree to the Photo Release terms*

Check to confirm
Agreement to work under the following conditions:

I understand that alcohol and/or illegal drugs of any kind are NOT permitted on campus at any time. If it is discovered that I am using alcohol and/or illegal drugs of any kind on campus, I understand that those actions are grounds for immediate dismissal from Camp Big Heart and a possible one year suspension from working at Camp Big Heart the following year. I also understand that it is my sole responsibility to make sure that any prescription medications that I bring on campus are safely and discreetly placed in my luggage at all times. CAMP BIG HEART IS NOT RESPONSIBLE FOR ANY STAFF AND/OR VOLUNTEER MEDICATIONS.

I understand that the applicant’s transportation to and from Camp Big Heart is my responsibility. The applicant and/or legal guardian will be responsible for transportation, as well as room and board arrangements for the Friday evenings after each session, as no one will be allowed to remain on campus. CAMP BIG HEART IS RELEASED FROM RESPONSIBILITY FOR ALL STAFF AND VOLUNTEERS DURING THE ABOVE MENTIONED TIME PERIOD.

Preplanning Sessions

I understand that all staff and volunteers are required to attend the staff orientation for each session they will be working. These will take place on Saturday afternoon on the first day of each session. We will specify what time you should be there well in advance of camp by e-mail.
I have read and agree to the above terms *

Check to confirm
I attest that all of the given information is true to the best of my knowledge. I consent for Camp Big Heart to perform a complete background check. I also agree to abide by the rules and regulations set forth in the Camp Big Heart Manual and by the Camp John Hope Administrators.
Signature of Applicant*

First NameLast Name
Date*

MonthDayYear
Signature of legal guardian, if applicant is a minor

First NameLast Name
Date

MonthDayYear
Should be Empty:

Civitan's Camp Big Heart 2024 Nursing Application

Identifying and Contact Information

Desired Position

Emergency Contact

If this is your first time at camp, fill out the following sections.

Certifications and Skills

Medical Information