Counselor Registration Form

Name

First NameLast Name

Birth Date

MonthDayYear

Driver's License Photo:

Age

Gender

MaleFemale

Cell Number

Email

example@example.com

Marital Status

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Health Insurance Company:

Health Insurance Company

Policy #:

Policy #

T-shirt Size:

Employment Information

Employer:

Employer

Position:

Position

Employer Phone Number

Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Alt. Phone Number

Do you have any allergies, chronic illness, or medical conditions? If yes, please describe.

List any first aid, CPR, or lifeguard experience, including expiration dates:

List any prior counseling, recreational, or leadership experience with children:

Have you ever been convicted of a crime including sexual related, or child abuse related offenses? Indicate Yes or No. If yes, please explain:

Informed Consent and Acknowledgement

Alcohol: Possession or consumption of alcohol is strictly prohibited, regardless of location. If there is suspicion of alcohol use, you will be asked to leave the premises immediately and law enforcement will be notified and you will be cited or arrested. State law prohibits alcohol in state parks.

Tobacco: Adults may only use tobacco in designated areas, away from campers.

Illegal Drugs & Weapons: The possession of illegal substances or weapons is strictly forbidden and will result in immediate removal from camp and law enforcement will be notified and you will be cited or arrested.

Camp Boundaries: Campers and counselors must remain within the designated camp areas at all times.

Curfew: Campers must be in their designated cabins at lights out. Counselors may remain outside, but at least two counselors must be inside each cabin while campers are asleep. Counselors are expected to be in their cabins no later than 1:00 AM.

Cabin Assignments: Male campers are not allowed in female cabins, and female campers are not allowed in male cabins. Cabins must be kept clean and damage-free. Any damage should be reported to staff immediately. Air conditioning settings are not to be adjusted.

Supervision & Safety: Campers must always be under the direct supervision of a counselor. A counselor should never be alone with a camper. At least three people (two adults and a camper) should be present at all times. Counselors must use sound judgment and be proactive in ensuring a safe environment.

Liability: All counselors must exercise caution in working with campers and anticipate any potentially hazardous situations. Good judgement must be utilized. Each counselor must recognize the consequences of his/her behavior when with the campers. Conscientous supervision at all times is mandatory. The welfare and safety of each camper is extremely important.

Privacy & Respect: Counselors and campers should respect each other's privacy and avoid inappropriate comments or actions regarding weight, speech, gender, race,religion, or other personal attributes. While this is a communal setting, all individuals deserve respect and personal space.

Relationships & Boundaries: Personal relationships among counselors should remain appropriate and should not interfere with camp operations. Any concerns should be brought to the coordinator’s attention.

Campers may develop strong emotional connections with counselors. Counselors should remain professional and maintain appropriate boundaries.

Physical Contact: Avoid physical contact in areas normally covered by a bathing suit or in any manner that may make someone uncomfortable.

Behavior & Professionalism: If a camper exhibits behavior issues, seek assistance from cabin leaders. If necessary, escalate to the coordinator. Raiding cabins is prohibited, as it often leads to property damage and disruption. While friendly interactions with campers are encouraged, always maintain professionalism and be mindful of physical interactions. If you are unsure about an action, do not do it.

Punctuality: Camp operates on a relaxed schedule, but for scheduled meetings and activities, timeliness is essential. Ensure that both you and your camper arrive on time.

Signature

Photo and Film Consent and Release Agreement

I will be attending Camp Amigo from June 28- July 3, 2025 and will be participating in activities offered. I give permission to Children's Burn Camp of North Florida, Inc. (Camp Amigo) to take photographs (digital or otherwise) and video footage of me. I understand that photographs and video that include me may be used to provide the general pubilc and others information regarding burn injuries and prevention, and to inform them of camps like ours.

Signature

Release of Liability

I will voluntarily be participating in activities provided at Camp Amigo from June 28-July 3, 2025. As I am voluntarily participating, I hereby release liability, and agree that no claims will be made by me, my family, or my estate against Children's Burn Camp of North Florida, Inc. (Camp Amigo), and/or any burn centers or hospitals attending or being represented at camp due to any injuries or damages sustained while attending camp.

I further agree that if I require medical treatment and can no longer communicate, I authorize the Camp Director, or any member of the medical staff to give authorization for medical treatment. I understand and agree that Children's Burn Camp of North Florida, Inc. (Camp Amigo) does not assume legal or financial responsibility for payment of any medical claims not covered by my insurance company.

I understand that no fees are charged to me for attending this camp and I am here as a volunteer.

I agree to and will abide by the NO ALCOHOL OR ILLEGAL SUBSTANCES policy.

Signature

Confirmation

I certify that, to the best of my knowledge, the above information is true and correct and I agree to release my medical information, if necessary.

Signature

Date

Summer Camp Amigo Counselor Registration