New Counselor

Leadership Development Program

2016 Adult Volunteer Application

November 11-13

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail

Phone Number

Area CodePhone Number

T-Shirt size

Sweatshirt size

Please list your years of involvement with Camp Horizon summer camp and role(s) each year.

Please list your years of involvement with the Leadership Development Program.

If selected as an adult volunteer for Camp Horizon LDP, indicate which roles and activities you would be interested in helping with or leading while at the LDP weekend. Please check your top two choices from the following:

Other

What age group would you prefer to work with while at the LDP weekend? (Your preference does not guarantee you will be with that age group)

If there are particular campers you would like to work with because of a previous camp relationship, please list them here. (Every effort will be made to accommodate reasonable requests, however, this is not a guarantee)

Are you able to transport youth to and from CTL for the weekend?

Are you able to ride as a passenger with someone transporting youth to and from CTL for the weekend?

If able to assist with transportation, which DFCS office do you prefer to transport/ride from?

Number of seat belts, NOT INCLUDING yours?

Are you willing to drive a rented mini-van if necessary?

DIETARY NEEDS: * please understand that allergy restrictions will be STRICTLY enforced at CTL this year, so if you select "gluten free, dairy free, or vegetarian", you will be expected to maintain that throughout the week. If you do not select this criteria in advance, it will not be available.

Other

Any additional information we need to know:

Have you ever been arrested, charged or convicted of any crime other than a minor traffic violation?

If yes, indicate the date(s), place(s), and nature of the offense(s).

Have you ever been arrested, charged or convicted of any crime involving violence of any nature?

If yes, indicate the date(s), place(s), and nature of the offense(s).

Have you ever been the subject of any investigation involving sexual abuse, sexual assault or sexual misconduct?

If yes, indicate the date(s), place(s), and nature of the offense(s).

Have you ever been reported to the Department of Family and Children Services (or any state's equivalent department/agency) for child abuse and/or neglect?

If yes, indicate the date(s),place(s) and nature of the offense(s).

Camp Horizon's policy is to prohibit all forms of harassment by our volunteers. This includes sexual, racial, religious, and other forms of harassment. Have you ever been involved in any investigation of harassment including, but not limited to, workplace harassment?

If so, please explain.

The next phase of the application process includes a background investigation. Are you willing to authorize Camp Horizon, Inc. to conduct an investigation including, but not limited to, a criminal history check?

Your application will not be considered complete without your signature following the "Applicant's statement and certification" below.

Applicant's statement and certification: I hereby affirm, attest, and certify that the information contained in this application and all representations made to CAMP HORIZON, INC., herein are true and correct and that I have not knowingly withheld any pertinent material, facts or circumstances. I understand that any omission or misrepresentation of fact in this application may result in refusal or separation from volunteer service upon discovery thereof. I fully authorize the persons, organizations, and agencies identified in this application to release to CAMP HORIZON, INC., its agents, or designees any and all information needed to determine my moral character and fitness to serve as a volunteer with children associated or unassociated with CAMP HORIZON, INC. I further release CAMP HORIZON, INC., its agents, Board Members, assignees, and designees from any and all liability including but not limited to any physical, mental, emotional, or financial damage that may result from my performance of any service to CAMP HORIZON, INC., or from allowing CAMP HORIZON, INC. to receive any information it has requested to determine my moral character and fitness as a volunteer.

Signature

Date:

The intent of this portion of the application is to help Camp Horizon, Inc. provide a safe and secure environment for the young people who participate in its programs.