Print in Black Ink. ALL Information must be completed for application to be approved.
Name ______Maiden/Alias ______c Male / c Female
Street Address ______City ______County ______
State ______ZIP ______Drivers License # ______c Single, c Married, c Divorced
Home Phone ( ) ______Cell Phone ( ) ______
Work Phone ( ) ______Email ______
Your Date of Birth ______/ ______/ ______Age ______Social Security Number ______
(Required! … Youth Leaders KRS 17.160)
Have you ever been convicted of a crime? c Yes / c No If yes, explain ______
Note: Background investigations will be conducted on all applicants.
Please attach a Copy of Insurance/Medical Card and a Recent Photo.
Insurance ______Medical Card # ______
Doctor’s Name ______Phone ( ) ______
Emergency Contact (Someone who can be reached in case of an accident or emergency):
Name ______Relationship ______Phone ( ) ______
New Applicants: Please submit a one-page letter describing why you would like to become a member of Camp Heart to Heart’s staff. Tell us about your abilities, how you can contribute to the camp and your experiences in working with children. Please include two (2) letters of recommendations from community members (i.e. teacher, minister, employer, co-worker, etc.)
Your Employer: ______Occupation: ______
Employer’s Address ______
Reference Name: ______Phone ( ) ______
Reference Name: ______Phone ( ) ______
Describe your swimming ability ______Do you have any prior Counselor Experience? c Yes / c No
School/College: ______Education/Certificates: ______
Special Talents & Skills: ______
Can you stay for the duration of the camp (days & nights)? c Yes / c No. If not, please give dates and times when you can attend ______
Will you require transportation to and/or from camp? c Yes / c No. Can you provide transportation? c Yes / c No
May your picture be taken for the Camp Album? c Yes / c No. May your picture be taken for the use of promoting Camp Heart to Heart? c Yes / c No. Are you a Lions Club member? c Yes / c No.
T-shirt Size: Adult: c Small / c Medium / c Large / c XL / c XXL / c XXXL
Continue to page 2 and complete all information!
Mail Application to: Camp Heart to Heart
c/o Lions Camp Crescendo Deadline Date:
P.O. Box 607 Return by May 20, 2016
Lebanon Junction, KY 40150-0607
Print Name: ______Date of Birth: _____/_____/_____
CONSENT FOR NON-PRESCRIPTION MEDICATIONS
This consent allows appropriate Camp Heart to Heart and Lions Camp Crescendo staff to give you over-the-counter medications as needed. Individuals under the age of 18 require Parent/Guardian’s signature.
Page 1 of 3 For additional information call or (502) 294-5872 or (502) 417-1960 or Toll Free 1-888-879-8884
c Yes / c No Tylenol
c Yes / c No Ibuprofen
c Yes / c No Tums
c Yes / c No Chloraseptic Spray
c Yes / c No Chloraseptic Lozenge
c Yes / c No Halls or Vicks Cough Syrup
c Yes / c No Triple Antibiotic Ointment
c Yes / c No Calamine Lotion or Caladryl Clear
c Yes / c No Sting Kill
c Yes / c No Hydrocortisone Cream
c Yes / c No Aloe with Lidocaine
c Yes / c No Sudafed
c Yes / c No Imodium A-D Caplets/Liquid
c Yes / c No Emetrol
c Yes / c No Benadryl
c Yes / c No Desitin
Page 1 of 3 For additional information call or (502) 294-5872 or (502) 417-1960 or Toll Free 1-888-879-8884
List other non-prescription drugs that you can take: ______
______
List all chronic illnesses:
______
List all prescription medications you are currently taking: ______
Present health condition is: ______Year of last Tetanus shot: ______
List any physical limitations: ______
List all food items and/or medicines you are allergic to: ______
Are you a vegetarian or vegan? c Yes / c No Do you have dietary restrictions? c Yes / c No
List any special food requirements or restrictions that you have:
______
Statement of Release & Authorization (Signature required for approval of application!)
- I hereby agree to release and hold Camp Heart to Heart and Lions Camp Crescendo’s staff free and harmless for any claims, demands, or suits for damages from any injury or complication that may result from the proper administration of the prescription/non-prescription medications I have listed or voluntarily marked “yes”.
- In case of an EMERGENCY, where I need to be seen by a physician, I hereby give my permission to be transported to a medical facility or hospital for the purpose of conducting examinations, ordering x-rays, administering tests and/or receiving EMERGENCY treatment. (Bring copy of DNR if applicable)
- I agree to adhere to all rules and regulations as set forth by camp administrative, directive and/or medical personnel.
Signature ______Date ______
(Applicant)
Signature ______Date ______
c Parent / c Guardian (Required if Applicant is under 18 years of age)
Note: You will be responsible for adhering to any drug regiment for any prescription medications you may be taking while attending camp (if you are under the age of 18, our nurse will dispense your medication). There will be a safe place provided for storage of your medicines, so we can insure our campers do not have access to them. You will have access to your medications at any time. However, we require that you provide our nurse with a list of your medications, dosages, and instructions for usage upon arrival at camp. This is required in case of emergencies. Thank you for your cooperation.
Usage of alcohol or illegal / illicit drugs will not be permitted at any time during the camp session!
Expectations for all Volunteer Counselors/Staff Members
Volunteer Minimum Requirements: Desire and ability to work with children; Ability to relate to one’s peer group; Ability to be a positive member of a staff team; Ability to accept supervision and guidance; Good character, integrity and adaptability; Enthusiasm, sense of humor, patience and self-control; Minimum age of 16, unless personally approved by the Camp Director;
Responsibility: Camp is not a vacation for volunteers. While there are delightful moments and personal gratification, it must be distinctly understood that a volunteer position at a Lions camp means hard work, long hours and definite responsibilities. You must be prepared to be a role model and friend to the children. You must be able to withstand summer heat and the outdoor activities. Camp is a fun time for the children to be away from home, learn new things as well as play and make new friends. The camp is for the campers, their safety and security are our first concern. Harassment of any kind, involving a camper or another staff person will be not tolerated.
Loyalty: Loyalty to the Directors and Camp Management is a necessity. Criticism of equipment, management, program, food or policies in the presence of campers is inappropriate. Counselors are expected to take their troubles/concerns/grievances to the Directors. Helpful suggestions are always welcome.
Character: There is no place at Camp for questionable ideals, vulgar/profane language, smutty jokes, personal sex-life stories, negative comments or poor sportsmanship. Every counselor is expected to conduct themselves with the highest moral stature. Destruction of camp property, vandalism or theft will not be tolerated. Smoking is not permitted in any building or in front of any camper.
Personal Appearance and Hygiene: Counselors are expected to maintain good hygiene and to dress appropriately for a children’s camp.
Child Abuse of any kind, suspected or known, is to be reported immediately to the camp director and administrator.
Weapons, Alcohol, Illegal Drugs: These items/substances are Not allowed on the camp property. Abuse of these items will not be tolerated. Weapons of any type (concealed or visible) are also not permitted on camp property.
Animals/Pets: Are only allowed inside buildings when they are “work” animals.
I understand and agree that I will adhere to the above conditions and policies. This form is to be returned with the Counselor application.
______
Name Signature Date
______
Parent Name (if child is under 18 years of age) Signature Date
Page 1 of 3 For additional information call or (502) 294-5872 or (502) 417-1960 or Toll Free 1-888-879-8884