Camp Hope Counselor

Volunteer Application 2014

General Information

First name / Last name / Middle name
Street address/apartment number
City / State/Province / Zip code
Date of birth / Gender
Male Female
Home number / Cell number
Email address
Best time to reach you (time & location) / T-shirt size (adult sizes)
S M L XL XXL XXXL
Occupation / Retired?
Yes No
Employer
Work telephone / May we contact you at work?
Yes No
Student?
Yes No / School
Major/Year
Emergency contact name / Relation / Phone

History/Interest

If you have volunteered with the National Multiple Sclerosis Society before, please share with us what you did and when.

How did you learn about Camp Hope and this volunteer opportunity?

What about this Camp Hope volunteer position appeals to you?

Do you have a personal connection to multiple sclerosis? If so, please describe.

Accommodations

Are you physically capable of:

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__ Walking more than one mile

__ Walking up and down stairs

__ Walking more than two miles

__ Being active from 7 a.m. to 10 p.m.

__Being active in summer temperatures (above 80 degrees) for long periods of time

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Please list below any special needs or limitations we should know about (physical, emotional, dietary, etc.):

Are you able to provide your own transportation to Camp Hope?

__ Yes __ No

Are you interested in carpooling to Camp Hope?

__ Yes __ No

If yes, may we distribute your contact information to other volunteers for purposes of carpooling?

__ Yes __ No

Experience (No special experience is required)

Please describe your experience (paid or unpaid) working with youth, including any experience with youth who have medical and/or behavioral issues:

Please describe any personal experience you have as a camper:

Please list your experience as a camp counselor, including type of camp and age of campers you counseled:

Do you have experience/expertise with any of the following? (check all that apply)

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__ Team sports

__ Group facilitation

__ Team building initiatives

__ CPR

__ First Aid

__ Lifeguard

__ Camp songs

__ Arts & crafts

__ Icebreakers

__ Canoeing

__ Hiking

__ Musical instrument

Please specify ______

__ Other

Please specify ______

______

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Please tell us more about any of the above training or experience:

Age Preference

In each box below are the age groups, please place a 1, 2 or 3, as follows:

1= preferred age group

2 = comfortable with this age

3 = would prefer not to work with this group

8-10 years old / 10-12 years old / 12 –15 years old
Your choice:

Camp Hope Volunteers: References

Please provide contact information for two references. References must be non-family members and at least one must be a present or former teacher, employer, pastor or other person of authority. References are for NEW volunteers only. Returning volunteers DO NOT have to provide this information.

Name / Relation
Address
City / State / Zip
Email / Phone
Name / Relation
Address
City / State / Zip
Email / Phone

Confidentiality policy

All registrants of the National Multiple Sclerosis Society, Gateway Area Chapter have a right to know that all personal records, documents and conversations shall remain confidential. No information which might individually identify a registrant with multiple sclerosis will be released by any staff member or volunteer of the National Multiple Sclerosis, Gateway Area Chapter to anyone outside the agency without the registrant’s express consent.

I have carefully read and understand the Confidentiality Policy and agree to serve as a volunteer in accordance with this policy.

Signature ______Date ______

Adult waiver and HIPAA statement

In signing this release, I understand the intent thereof, and will for myself, executors, administrators, and assigns hereby release the National MS Society, Gateway Area Chapter and all sponsoring agencies, organizations and their respective agents and employees from all claims of damages, action, and causes of actions whatsoever, in any manner as a result of my participation in programs/activities sponsored by the Gateway Area Chapter.

I understand that if I do not meet my responsibilities while at Camp Hope I will be asked to leave at my own expense.

I hereby give permission to use the information in the Camp Hope application packet for the sole purpose of Camp Hope. I understand that medical information may be used to help determine appropriate camp assignments and accommodations, and to ensure that the camp nurse can assist me with my medical needs if necessary. By signing this form, I am giving the camp staff permission to communicate with my emergency contact and share my condition, if deemed necessary.

Signature ______Date ______

Witness name

______

Printed Signature

Media Release

I grant permission to the National MS Society, Gateway Area Chapter to use my name and/or image in any media, either alone or accompanied by any other material. I agree that I will not hold the MS Society responsible for any liability resulting from the use of my name and/or image in the manner described above.

Signature ______Date ______

Send completed application to:

Stacey Sickler, National MS Society, Gateway Area Chapter,

1867 Lackland Hill Parkway, St. Louis, MO 63146

Phone: 314-446-4184 Fax: 314-432-2307 Email:

The next page is a reference form you can give to your chosen references to fill out and return back to me, or they can return to you and you can include it with the rest of your paperwork.

Counselor Reference Form

Camp Hope 2014

Dear _____,

has applied to be a Camp Hope counselor with the National Multiple Sclerosis Society, Gateway Area Chapter and has given your name as a reference. Since volunteers can work closely with children, we would appreciate your candid feedback regarding the suitability of the applicant to volunteer. All information received will be confidential.

1. How long have you known the applicant? ______

2.  In what capacity have you known the applicant? ______

3.  When was the last time you had contact with this person? ______

4.  How well do you know the applicant? Very Well Well Little Very Little

5.  Do you know any reason why the applicant would not serve well as a volunteer?

No Yes If yes, please explain: ______

6.  How would you judge the applicant’s reliability? Excellent Good Fair Poor

7.  Please comment on the applicant’s qualities that you feel would make him/her a good volunteer: ______

8.  Any additional comments or information that you feel would be helpful to us: ______

Signature Date______

Thank you for taking time to complete this questionnaire!

Please send completed reference form to:

Stacey Sickler, National MS Society, Gateway Area Chapter,

1867 Lackland Hill Parkway, St. Louis MO 63146

Phone: 314.446.4184 Fax: 314.432.2307 Email:

Counselor Reference Form

Camp Hope 2014

Dear _____,

has applied to be a Camp Hope counselor with the National Multiple Sclerosis Society, Gateway Area Chapter and has given your name as a reference. Since volunteers can work closely with children, we would appreciate your candid feedback regarding the suitability of the applicant to volunteer. All information received will be confidential.

1. How long have you known the applicant? ______

9.  In what capacity have you known the applicant? ______

10.  When was the last time you had contact with this person? ______

11.  How well do you know the applicant? Very Well Well Little Very Little

12.  Do you know any reason why the applicant would not serve well as a volunteer?

No Yes If yes, please explain: ______

13.  How would you judge the applicant’s reliability? Excellent Good Fair Poor

14.  Please comment on the applicant’s qualities that you feel would make him/her a good volunteer: ______

15.  Any additional comments or information that you feel would be helpful to us: ______

Signature Date______

Thank you for taking time to complete this questionnaire!

Please send completed reference form to:

Stacey Sickler, National MS Society, Gateway Area Chapter,

1867 Lackland Hill Parkway, St. Louis MO 63146

Phone: 314.446.4184 Fax: 314.432.2307 Email:

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