Miracle Burn Camp

Miracle Burn CampVolunteer Application

First Time Applicant

Must be submitted by March 31, 2017

Name: ______Birthdate: _____/_____/_____

Address:______

City/State/Zip: ______

Home/Cell Phone: ______Work Phone: ______

E-Mail: ______

Gender Identity: ______

EDUCATION

Post High School/Trade Colleges attendedDegree/Certification

1) ______

2) ______

3) ______

Please list any certifications you currently hold (e.g., CPR, First Aid, Water Safety Instructor):

CertificationExpiration Date

1) ______

2) ______

3) ______

EMPLOYMENT

Please list below your last three jobs beginning with your current/most recent.

Employer NamePhone numberYour JobTitleEmployment Dates

1) ______

2) ______

3) ______

TELL US ABOUT YOURSELF

1) Why are you interested in being a Miracle Burn Camp volunteer?

2) Explain how you will have a positive influence on campers this summer.

3) What would you want a burn injured child to gain from a summer camping experience?

4) Working at Miracle Burn Camp is challenging both physically and mentally. What do you anticipate those challenges will be for you and how will you meet them?

5) What have we forgotten to ask? Please provide any additional information that you feel our staff should know to make this volunteer experience successful for you.

REFERENCES

List below three (3) persons you intend to use as references (References may be a combination of professional and personal. There must be at least one professional reference. Personal references may NOT include a family member).

NameEmail AddressRelationshipPhone number

1) ______

2) ______

3) ______

Have you ever been previously convicted of a felony or misdemeanor?

Yes_____ No _____ If yes, please indicate the conviction(s), dates, and circumstances

______

Please initial each statement below to indicate your agreement and then provide your full signature.

_____I hereby certify that this application contains no willful misrepresentations and that the information given by me is true and complete to the best of my knowledge. I understand that misrepresentations or omissions of any may result in denial of volunteer status or be cause for subsequent dismissal from volunteer status.

_____I recognize that this application is not and should not be considered a guarantee of volunteer status. I understand that being a St. Florian Fire & Burn Foundation volunteer at Miracle Burn Camp is on an at-will basis and that my volunteer status may be terminated with or without cause, and without notice, at any time, at my option or at the option of St. Florian Fire & Burn Foundation.

_____I authorize St. Florian Fire & Burn Foundation to investigate my background and responses on this application and to contact any individuals familiar with me or my employment background for the purpose of verifying any information and/or for the purpose of obtaining any information about me or my employment. I voluntarily and knowingly fully release and hold harmless any person or organization that provides information about me or my employment.

______

Signature Date

Miracle Burn CampVolunteer

Health Information Form

Name: ______

Birthdate: ______

In case of an emergency please notify, in order of importance:

NameRelationshipPhone number

1) ______

2) ______

Name of insurance company for health and accidents:

Policy Number: ______Group #:______

Family Doctor: ______Phone #: ______

Please document the last date of the Diphtheria, Pertussis, Tetanus (Tdap) or Tetanus-diphtheria (Td):______

You must have had a tetanus vaccine of some type within the past 10 years.

Please list any allergies. Please state if the allergy is mild, moderate, or severe, and describe your action plan for your allergy.

Allergy Mild/Moderate/SevereAction plan

______

Do you take any medications (including prescription and over-the-counter)? Please list: ______

______

All prescription medication must be in its original packaging that identifies the prescribing physician, the name of the medication, dosage, and frequency. All medication should be submitted to the Health Center. All medication must be locked securely unless in the immediate possession/control of the user (e.g., inhaler, epi pen).

Please return by March 31, 2017 to:

Nancy Johnson

Miracle Burn Camp Co-Director

UIHC

Department of Spiritual Services

200 Hawkins Drive

Iowa City, IA 52242