Camp Crescent Moon 2025 Medical Team

CCM Medical Team Volunteer Application

Camp Dates - July 20-25, 2025
Thank you for being 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. 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/DONPRNLVNSocial Worker (BSW/MSW/LCSW)PsychologistPAOther
Specialty (select all that apply)*

PediatricsAdultsTeensOther
License # (if applicable)
Required for MD/DO, NP, RN, LVN, PA
State licensed (if applicable)
Please upload copy of medical/professional license:

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Profession (check all that apply)*

MD/DONPRNLVNRN Student (limited availability)LVN Student (limited availability)Social Worker (BSW/MSW/LCSW)PsychologistPAOther
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

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 20-25, 2025 (this is Sunday to Saturday)*
If no, please select days of availability (shift time is approximately 8:00 am - 8:00 pm)

Sunday, July 20thMonday, July 21stTuesday, July 22ndWednesday, July 23rdThursday, July 24thFriday, July 25thSaturday, July 26th (end of camp - approximately 1:00 pm)Other
Dietary Preference (we may not be able to accommodate vegan only options)*
Comments
Camp Sleeping Accommodations - I will be:*
What is your T-shirt size?*
What is your Hoodie size?*
Depending on funds, hoodies may be provided to volunteers this year
RELEASE FOR EMERGENCY TREATMENT AND LIMITATION OF LIABILITY

I am a VOLUNTEER over 18 years of age who will travel to and attend Camp Crescent Moon during the dates of July 19-27, 2025.

Pursuant to California Family Code §6910, I hereby authorize the Director, Doctor or Nurse of Camp Crescent Moon to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care to be rendered to the minor under the general or special supervision and upon the advice of a physician and surgeon licensed by the Medical Board of California, or consent to any x-ray examination, anesthetic, dental or surgical diagnosis or treatment, and hospital care to be rendered to the minor by a dentist licensed by The Dental Board of California.

This authorization shall be effective whether such diagnosis, treatment or care is rendered at the office of said physician or dentist, at a hospital, at Camp Crescent Moon, or elsewhere, and shall remain effective while I am in route to or from or involved or participating in any program or activity of Camp Crescent Moon, unless earlier revoked by me in writing and delivered to the Director.

I hereby acknowledge that for proper functioning of Camp Crescent Moon, a unique summer camp exclusively for children with sickle cell disease, it is necessary that the doctor/nursing/therapist staff at the camp be able to discuss the Volunteer’s health issues with the non-medical counseling and other staff so that the volunteer staff is able to assist with providing a camp experience which is sensitive to and consistent with the me, the Volunteer’s health issues, limitations, and requirements.

While the camp volunteer staff does not provide health care, they need to understand the health conditions to assure that activities are tailored to the needs, abilities and limitations of those attending the camp. I further acknowledge that discussions between the doctors and nurses and the non-medical staff may be filmed for promoting interest in Camp Crescent Moon by the general public and by potential donors. The undersigned acknowledges that such discussions may include medical record information pertaining to me, the Volunteer. I further understand that such film may be submitted to news organizations and other commercial broadcast facilities for human interest coverage of the Camp, its campers and staff or used at Camp Crescent Moon fundraising functions or to supplement a Camp Crescent Moon speech to hospitals, businesses, groups or organizations.

In full consideration of the foregoing, the undersigned hereby authorizes the medical staff of Camp Crescent Moon, including without limitation, its doctors, nurses, therapists, as applicable, to disclose the undersigned’s full medical record information to the non-medical staff of Camp Crescent Moon for the purposes stated above and the undersigned further authorizes that such medical information discussions between the medical staff and non-medical staff at Camp Crescent Moon may be filmed for the purposes stated above.

On my own behalf, I hereby expressly release, discharge and hold harmless Camp Crescent Moon, the Sickle Cell Disease Foundation and the Irvine Ranch Outdoor Education Center and their respective agents, employees, officers, directors and representatives, from any liability or responsibility relating to or arising from any damage, loss or injury sustained by me, the Volunteer while traveling to or from Camp Crescent Moon, while attending Camp Crescent Moon, while participating in any activities at Camp Crescent Moon or any trips or activities sponsored by the Sickle Cell Disease Foundation, or while staying in any accommodations provided or arranged by Camp Crescent Moon or by the Sickle Cell Disease Foundation, other than such liability or responsibility which may arise as a result of their gross negligence or willful misconduct.

Without limiting the generality of the foregoing, this release includes within its scope any loss, damage or injury sustained as a result of any ordinary negligence, whether active or passive on the part of Camp Crescent Moon, the Sickle Cell Disease Foundation, or any of their officers, agents, employees or representatives.

Camp Crescent Moon Sickle Cell Disease Foundation The foregoing release is to be construed in accordance with the laws of the State of California. It is intended to release claims which are known and which are as yet unknown. Accordingly, I hereby waive on my own behalf and on behalf of Volunteer, the provisions of the California Civil Code Section 1542 which provides: “A general release does not extend to claims which the creditor does not know or suspect to exist in his or her favor at the time of executing the release, which if known by him or her must have materially affected his or her settlement with the debtor.”

I have read and understood the Camp Crescent Moon Release for Emergency Treatment and Limitation for Liability, and my signature below acknowledges the information included in the Camp Crescent Moon Release for Emergency Treatment and Limitation for Liability.
Name*

First NameLast Name
Signature*

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Date*

MonthDayYear
Date
PUBLICITY RELEASE

For good and valuable consideration from the Sickle Cell Disease Foundation and Camp Crescent Moon, the adequacy and receipt of which I hereby acknowledge, I hereby expressly grant to the Sickle Cell Disease Foundation and Camp Crescent Moon, or any third party either of them may authorize, and to their employees, agents and assigns, the right to photograph me and/or make recordings of my voice, and the right to use pictures, recordings and other reproductions of my physical likeness or voice (as the same may appear in any still-camera photographs, videotape, and/or motion picture film) for any advertising, promotion, and/or fundraising, without any further compensation.

All such photographs, videotapes, motion picture films, and recordings, and all negatives or masters thereof, shall be the sole and exclusive property of the Sickle Cell Disease Foundation and Camp Crescent Moon. I hereby certify and represent that I have read the foregoing and fully understand the meaning and effect thereof and, intending to be legally bound.
Accept or Decline Publicity Release*
Publicity Release Signature*

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APPLICANT RELEASE & AUTHORIZATION FOR BACKGROUND CHECK

To ensure the safety of children, parents, staff, and volunteers at Camp Crescent Moon, a background check is required for each candidate before a volunteer position offer is made.

I hereby authorize the Sickle Cell Disease Foundation to obtain information pertaining to any to any charges or convictions I may have for federal and state criminal law violations. This information will include, but not be limited to; allegations and convictions committed upon minors, and will be gathered from any law enforcement agency of this state or federal government to the extent permitted by state andfederal law.

I also authorize all persons, public agencies, courts, schools, employers, companies and corporations to supply verification of the information provided in my application as well as evaluation of my prior performances and I release them from all liability from their doing so.

The above statements are true and complete to the best of my knowledge.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Driver's License #*
State Issued*
Has your driver's license ever been suspended or revoked?*
Have you ever been convicted of a criminal offense?*
Have you ever been charged with child abuse or neglect?*
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:*
Please Provide a Minimum of 7 Years of Residential History Below:*
Current Address*

Street Address

Street Address Line 2

CityState

Zip Code
County*
Please add the appropriate dates for residing at the address above. Date From Date To*
Previous Address #1

Street Address

Street Address Line 2

CityState

Zip Code
County #1
Please add the appropriate dates for residing at the address above. Date From Date To
Previous Address #2

Street Address

Street Address Line 2

CityState

Zip Code
County #2
Please add the appropriate dates for residing at the address above. Date From Date To
Background Check Signature*

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VOLUNTEER STAFF COMMITMENT STATEMENT

This form explains and clarifies the mutual commitment between yourself and Camp Crescent Moon.

Camp Crescent Moon serves children with sickle cell disease in California. Camp Crescent Moon nurtures the personal growth and development of campers and volunteer staff, enriching the human experience through a quality camping program.

As a volunteer camp staff member and representative of Camp Crescent Moon, you are the primary contact to our campers and their families. We are entrusting you with the critical nature of our mission and trust you to protect the best interests of Camp Crescent Moon and its participants in all ways.

By completing this form, you acknowledge your understanding of and commitment to these expectations. We, in return, acknowledge our commitment to you, and understand that you are entitled to certain expectations of Camp Crescent Moon as well.

As a volunteer staff member of Camp Crescent Moon, I understand that I am committing to:
1. Work constructively as part of a team with other volunteers/staff members and to positively resolve all conflicts
2. Complete all of the appropriate training needed to conduct my volunteer staff responsibility
3. Read all orientation materials
4. Adhere to Camp Crescent Moon performance standards, guidelines, ethical standards and the code of conduct
5. Place the best interest of Camp Crescent Moon above my own personal feelings while volunteering at camp
6. Represent Camp Crescent Moon professionally and positively to other volunteers, staff, donors, families, and the public
7. Respond to phone calls and e-mail messages within 48 hours whenever possible
8. Respect the confidentiality and privacy of campers and families • Give and receive constructive feedback in a positive manner
9. Notify the Camp Crescent Moon administrative staff of any potentially unethical situation involving myself or other staff/volunteers
As part of this mutual commitment, Camp Crescent Moon agrees to:
1. Provide a quality camp experience in which you have the opportunity to achieve personal growth
2. Provide you with appropriate and thorough training, proper tools and instruction
3. Provide a staff manual with performance standards
4. Provide constructive feedback, coaching and conflict resolution
5. Be professional and courteous at all times and appreciative and respectful of your time
6. Respond to phone calls and e-mail messages within 48 hours whenever possible
Volunteer Staff Commitment Signature*

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Medical Team Volunteer Information Session

This required session will be held virtually.
Please select the Virtual Medical Team Volunteer Information Session you can attend in preparation to volunteer in the Infirmary for Camp Crescent Moon*
The zoom meeting link will be emailed to you shortly.
Thank you for your interest in volunteering at Camp Crescent Moon.

We will follow up with you shortly.

Upon submission of this application, you will receive the following documents via email for completion.

1. Medical History Form
2. Immunization Update (PPD, Tetanus & Hepatitis B)
Should be Empty:

CCM Medical Team Volunteer Application

Medical Team Volunteer Information Session