Personal Information:
Name:
First Name
Last Name
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Emergency Contact:
Phone:
Format: (000) 000-0000.
Employment/Educational Background
Name of Employer:
Job Title:
Education/Area of study:
Camp Interest:
How did you hear about Camp Eva?
Please share why you want to be a volunteer at Camp Eva:
Have you ever been a part of a kid's camp setting with grieving kids? If so, when and where:
Do you have special skills, interests or talents to offer at Camp Eva?
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Volunteer Medical History:
Please answer the following questions about your medical history.
Name:
Have you had chicken pox or shingles?
When?
Food Allergies:
Medication Allergies:
Other:
Please list any other medical issues that Our Hospice of South Central Indiana should be aware of during your time at camp (allergies, asthma, hay fever, seizures, etc.)
Please list any physical restrictions or limitations to be considered during the camp: (amputations, crutches, wheelchair, difficulty during physical activity, etc.)
Are your immunizations up to date?
Primary Care Physician:
Phone:
Format: (000) 000-0000.
References:
Please list two references who agree to participate in a phone call as a reference.
Name:
Relationship:
Address:
Phone:
Format: (000) 000-0000.
Name:
Relationship:
Address:
Phone:
Format: (000) 000-0000.
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Criminal Background Check:
Please answer the following questions. By completing this and signing at the bottom, you are giving Our Hospice of South Central Indiana permission to submit a background check through the state of Indiana. This will be done at no cost to you. Your information will be protected.
Have you ever been convicted of a felony or misdemeanor?
Yes
No
Have you ever been convicted of driving under the influence of drugs/alcohol?
Yes
No
If you answered yes to either of the above questions, please explain and give the dates of the occurrence and description of any criminal charges.
Have you ever been convicted of any crime relating in any manner to children and your conduct with them?
Yes
No
If yes, please explain:
Have you ever been convicted of a crime including, but not limited to, the following: alcohol related, assault and battery, kidnapping, distribution and trafficking of narcotics or other controlled substances, crimes of indecency, sexual related crimes, guns or weapons crimes?
Yes
No
If yes, please explain:
Have you ever been adjudicated liable for any civil penalties or damages involving sexual abuse, physical/ emotional abuse or neglect of a minor, or have you been the subject to any court order involving sexual abuse, physical/emotional abuse, or neglect of a minor?
Yes
No
Have you ever had an order of protection filed against you for any reason?
Yes
No
Have you ever had your parental rights terminated for any reason?
Yes
No
If yes, please explain:
Do you consent for Camp Eva (through Westside Community Church) to conduct a criminal background check?
Yes
No
Date of birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender:
Race:
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I understand that by submitting this signed application:
our Hospice of South Central Indiana will submit a criminal background check to the State of Indiana at no cost to me. My information and the results of this background check will be only used for purposes to appropriately staff the camp. This will be submitted through Westside Community Church background check system. The background check will be used as one element to determine my appropriateness to serve as a volunteer at Camp Eva.
Our Hospice of South Central Indiana may deny the opportunity for participation in Camp Eva to anyone who answers any of the proceeding questions affirmatively or who falsifies any information.
Our Hospice of South Central Indiana may deny participation by any applicant for any reason in the best interests of the children who will attend the camp.
I may be asked to provide additional information or explanation to Our Hospice of South Central Indiana.
I am expected to attend a training session prior to Camp Eva.
Signature of Applicant
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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