Civitan's Camp Big Heart 2026 Nursing Application

Civitan's Camp Big Heart 2026 Nursing Application
If you have any questions about this form or working at camp, please feel free to reach out to Dakota Harris at dakota.wallace@campbigheart.org or 678-633-1715.
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*
Format: (000) 000-0000.
Alternate Phone Number
Format: (000) 000-0000.
Your picture file must be named Firstname_Lastname
Recent Photo*

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SmallMediumLargeX-LargeXX-LargeXXX-Large
Desired Position
Desired Position*
SESSION 1: June 6 – June 12, 2026 (School Aged Campers)SESSION 2: June 13 - June 19, 2026 (Adult Aged Campers 18+)
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*
Format: (000) 000-0000.
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 3 non-family member references 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*
Format: (000) 000-0000.
Full Name*

First NameLast Name
Relationship*
Time Known*
E-mail*
example@example.com
Phone Number*
Format: (000) 000-0000.
Full Name*

First NameLast Name
Relationship*
Time Known*
E-mail*
example@example.com
Phone Number*
Format: (000) 000-0000.
Certifications and Skills
What is your license number?*
We will be looking into your credentials with the GA board of Nursing data base. Is there anything we should know prior to looking up your credentials?*
Are you certified in first aid or CPR? List any certifications you will have during camp. Include cert name, issuing agency, and the exp. date.*
Medical Information
Please list any allergies you have.
I affirm that I am up to date on all immunizations.*
YesNo
Describe any other dietary restrictions you have.
Seizure DisorderActive SeizuresDiabetesHeart ProblemsOther
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 ensure your application is processed.
Insurance Card (Front)*

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Insurance Card (Back)*

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Non-Disclosure Agreement
Have you ever been arrested and/or charged with a crime? (This includes all arrest and charges whether or not they were dismissed, deemed nolle prosequi, deferred adjudication, or found not guilty.) *
If yes, please explain:
Have you ever been convicted of any crime relating in any manner to children and/or your conduct with them? *
If yes, please explain:
Have you ever been convicted of any crime including, but not limited to, those listed below and/or any crime similar in any manner to those listed below? • Indecent assault and battery on a child under fourteen • Indecent assault and battery on a mentally retarded person • Indecent assault and battery on a person who has obtained the age of fourteen • Rape • Rape of a child under sixteen with force • Assault with intent to commit rape • Kidnapping of a child under sixteen with intent to commit rape • Distribution and trafficking of narcotics or other controlled substances • Intent to commit any of the above crimes. *
If yes, please explain:
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."
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.
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 2026 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

Non-Disclosure Agreement