Download application here

Dear Prospective Camp Sunrise Volunteer,
Thank you for your interest in becoming a member of the 2016 volunteer staff. We are excited to
host our very own Olympic Games this year. Camp Sunrise will be held from July 30 - August 6,
2016 at Camp Barrett in Crownsville, Maryland.
All staff must submit references, medical vaccination records and a current negative PPD result. In
addition, fingerprinting is required for all new staff members. Please go to your local CJIS office to
get fingerprints completed. The account number is 1000001995. The Department of Volunteer
Services of The Johns Hopkins Hospital will be handling all Camp Sunrise applications so
information must be timely.
This year we will have two deadlines for applications. All returning staff applications are due NO
LATER than May 1, 2016. New staff applications will be accepted until May 27, 2016 and must
include all necessary documents.
Camp Sunrise
C/O Marilyn Scalf
PO Box 50
Riderwood, MD. 21139-0050
Once we have received your application, the Department of Volunteer Services will process your
information. The Staff Director will contact you with any questions or special instructions. Once you
have secured a position as a volunteer, you must attend a mandatory camp orientation on July 30th.
We are looking forward to seeing you at camp!
Sincerely,
Marilyn Scalf
Chair/Staff Director
[email protected]
FOR OFFICE USE ONLY
Date App. Rec'd. __________________
Date of interview___________________
Disposition
_______
Alternate Comments: ______________
Camp Sunrise
July 30, 2016 - August 6, 2016
Johns Hopkins University
Pediatric Oncology Volunteer
Application
General Information (please print)
Name: _______________________________________ Male___ Female____
Address: _____________________________________E-mail:____________________
City:_______________________ State:_________
Home Phone: (____)__________________
Cell Phone: (______)__________________
Zip:__________
Work Phone: (_____) ________________
Date of Birth:_____/_____/______
Are you a U.S. Citizen? Yes ___ No ___ If no, indicate citizenship status: _______________
T-shirt size: S ___ M ___ L ___ XL ___ 2XL ___ Other size:_____________
Have you attended a camp before? Yes ___ No ___
If yes, what type of camp and in what capacity? _________________________________________
What position are you applying for:
□ Camp Counselor Staff □ Program/Activities Staff
Please check the activities you would be comfortable leading.
□ Campfire programs □Ropes Course □Team Sports □Photography □ Music/Singing
□ Story Telling □Arts & Crafts □Archery □Nature
Other: _______________________________________________
Do you speak a language other than English? Yes____ No ____
Specify: __________
Have you ever been convicted of a crime? Yes_____ No______ If yes, attach an explanation.
Are you certified in CPR? ___________ Are you certified in First Aid?____________
Professional License No./State: __________________/_____________
Please attach a copy of your professional license {A// information will be held confidential, unless specified otherwise).
Name: _________________
Employment & Volunteer History
Present employer:
Employer’s name: ________________________________________________________
Your position: ____________________________________________________________
Address: ________________________________
Supervisor's name: _____________________
Volunteer Experience (Most recent):
Position:
Position:
Phone: (______) ____________________
Employed since: _________________
Agency:
_____________
Agency:
Date(s):
Date(s):
_
_
Education & Youth Experience
Highest grade completed:
Special Training:
_
What experience have you had working with children? _____________________________________
_________________________________________________________________________________
Please identify what level of experience you have had working with children who have special educational
or behavioral concerns:
Please describe:
□ No Experience □ Some Experience □ A lot of Experience
What special gifts or talents would you like to bring to camp?
References:
List two people other than relatives who would be willing to serve as a personal reference.
Name:
Street Address:
Name:
Street Address:
Telephone number:
City:
Telephone number:
City:
Camp Sunrise Volunteer Application: Page 2 of 7
E-mail:
_____
State/Zip:
_____
E-mail:
______
State/Zip:
_____
Name: _________________
Agreement to take part in Camp Sunrise Overnight Activities:
I want to take part in all Camp Sunrise activities and, in consideration of the benefits to be derived I expressly
waive all claims against Johns Hopkins University, Johns Hopkins Health System Corporation and any of their
affiliates and, Camp Sunrise staff or their representatives on account of any accident, injury and or illness that
may occur during the camp period.
Signature of Volunteer
Date
Consent for Medical Treatment and Emergency Medical Treatment:
I hereby authorize the Medical Director of Camp Sunrise or such designee(s) as the Medical Director may
appoint, to provide for the giving of medical treatment and emergency medical care or treatment, including but
not limited to medicines, immunizations, x-rays, tests, dental and minor surgical treatment, hospitalization,
general anesthesia or other medical treatment as may be appropriate while in the care of Camp Sunrise.
Notification of the emergency contact will always be attempted prior to providing emergency medical treatment.
I understand that information pertaining to me may be shared with/released to appropriate personnel for the
purpose of treatment (including, but not limited to camp medical staff and/or insurance companies). I agree to
be financially responsible for the cost of all emergency medical care and treatment provided.
Signature of Volunteer
Date
Photo Release Permission:
I give permission for any photographs and/or videos that may be taken during the camp period and include my
likeness to be used in connection with video slide presentations, future program publicity, fund raising,
educational activities, or teaching purposes. I also give permission for these to be shared with program
participants (campers & staff). I waive any claims to compensation and rights regarding such use.
YES _______ NO __________ Signature of Volunteer ___________________________________
Permission to complete attitude surveys and program evaluation surveys:
I agree to anonymously fill out attitude and program evaluation surveys during Camp Sunrise programming.
Information from surveys will be used to evaluate the program and for educational or teaching purposes.
YES _______ NO __________ Signature of Volunteer ___________________________________
Applicant's Certification and Agreement
I certify that all information is true and has been given voluntarily. I understand that this information may be
disclosed to any party with legal and proper interest. I release the agency from any liability whatsoever for
supplying such information.
Signature of Volunteer
Date
Agreement of Confidentiality
My signature on this form indicates my understanding that any patient names or information I may receive
while participating as a volunteer at Camp Sunrise is confidential information and will be treated as such by
me.
Signature of Volunteer
Date
Permission to include contact information in Camp Sunrise Alumni & Staff Directory
I give my permission to include contact information about me in the Camp Sunrise Alumni & Staff directory
which will be distributed to program participants.
YES _______ NO __________ Signature of Volunteer ___________________________________
Camp Sunrise Volunteer Application: Page 3 of 7
Name: _________________
Persons to be contacted in case of an emergency:
Name: _____________________________________________________________
Home Phone: (____)
Other Phone: (____)
Name: _____________________________________________________________
Home Phone: (____)
Other Phone: (____)
Insurance Information
If Medicaid, specify number:_____________________________
Name of Insurance Company: ___________________________
Address: ____________________________________________
Phone Number: (____) _______________________________
Policy Number or CIN:_______________________________
If Group Insurance, specify company of employment: ____________________
Name of Policy Holder: __________________________
Social Security # of Policy Holder: ___________________________
Please include a copy of your insurance card.
Camp Sunrise Volunteer Application: Page 4 of 7
Name: _________________
In order to volunteer for Camp Sunrise you will need to meet all Johns Hopkins Medical Institution standards
regarding health status, vaccinations and immunizations. Please use the table below to determine the paperwork you
will need to give to us to obtain clearance from the Johns Hopkins Department of Occupational Health PRIOR to working
at Camp Sunrise
NEW and RETURNING
Camp Sunrise Volunteer
*****You WILL need to provide recent PPD results
Employee at Johns Hopkins ONLY
NOT an employee at Johns Hopkins
Measles Titers
Documentation of positive titers for measles
Documentation of positive titers for
measles
Mumps Titers
Documentation of positive titers for mumps
Documentation of positive titers for
mumps
Rubella Titers
Documentation of positive titers for rubella
Documentation of positive titers for
rubella
Varicella Titers
Documentation of positive titers for varicella
Documentation of positive titers for
varicella
Tuberculosis
Screening
Documentation of a negative PPD
obtained after
Documentation of a negative PPD obtained
after
July 31, 2016
May 1, 2016
**Please provide a copy of your immunization history**
Camp Sunrise Volunteer Application: Page 5 of 7
Name: _________________
General Health History, Page 1 of 2
Do you currently have, or have had in the past, any of the following medical conditions?
HEART PROBLEMS
MUMPS
SEIZURES
MEASLES
DIABETES
GERMAN MEASLES
DEPRESSION
ASTHMA
CANCER
OTHER
lf yes or other please explain: __________________________________________________________
__________________________________________________________________________________
(If you checked "Yes" to Cancer, please fill out the additional section on the following page.)
Do you have any difficulties and/or medical conditions related to the following?
EARS
THROAT
ARMS/LEGS
EYES
LUNGS
OTHER
NOSE
DIGESTION
lf yes or other please explain: __________________________________________________________
__________________________________________________________________________________
IMMUNIZATION HISTORY: (All immunizations must be kept up to date.)
DPT SERIES
LAST TETANUS BOOSTER __________________________
POLIO BOOSTER
LAST TUBERCULIN (PPD) TEST ______________________
INFLUENZA
MMR (MEASLES, MUMPS, RUBELLA)__________________
VARICELLA ________________
**Please provide a copy of your immunization record**
ANY RECENT OR CURRENT INFECTIOUS OR COMMUNICABLE DISEASE EXPOSURE?
(PLEASE EXPLAIN): ________________________________________________________________
TREATMENT RECEIVED:____________________________________________________________
ALLERGIES:
MEDICATIONS
□ YES
ENVIRONMENTAL □ YES
□ NO
□ NO
□ NO
FOODS
INSECT STINGS
□ YES □ NO
□ YES □ NO
OTHER
□ YES
lf yes or other please explain: __________________________________________________________
__________________________________________________________________________________
DO YOU HAVE ANY RESTRICTIONS RELATED TO:
□
□
□
□
DIET: ____________________________________________________________________
SWIMMING/DIVING: ________________________________________________________
ACTIVITY LEVEL: __________________________________________________________
OTHER: __________________________________________________________________
Camp Sunrise Volunteer Application: Page 6 of 7
Name: _________________
General Health History, Page 2 of 2
MEDICATIONS· MEDICATI ONS MUST BE BROUGHT IN ORIGINAL PHARMACY CONTAINERS
DRUG
DOSE
TIME
. DAYS OF WEEK
Primary care doctor's name: _________________________Phone number: _____________________
Date of last visit: _____________________________________________________________
Hospital:_____________________________________________________________
Fax number: _______________________________
Address: _________________________________________________________
CANCER HISTORY [to be completed if you answered "Yes" to Cancer]
Type of Cancer Diagnosis:_________________________________________________
Date of Diagnosis: ________________________________________________________
What years did you receive cancer treatment? ______________________________
What treatment did you receive?
□ Chemotherapy
□ Radiation
□ Surgery
□ Other
If Other, please explain: ____________________________________________________
Are you currently receiving cancer treatment? □ YES
□ NO
lf Yes, please list treatments: __________________________________________________________
Do you currently have any lines/devices (Port, PICC, Hickman, VP shunt, etc.)? □ YES
□ NO
If yes, please list type and date inserted: __________________________
Do you have any chronic medical conditions related to your cancer treatment: □ YES
□ NO
If Yes, please explain: ______________________________________________________________
Date of last visit to Oncologist: _________________________________________________________
Oncologist Name: ____________________________ Phone number: _____________________
Hospital: ___________________________________ Fax: ______________________________
Address: _______________________________________________________________________
Camp Sunrise Volunteer Application: Page 7 of 7
Name: _________________
PINKERTON
CONSULTING & INVESTIGATIONS
Background Information Form
PLEASE PRINT CLEARLY
Last Name
First Name
Middle Name
Maiden/Alias Names
Date of Birth
Social Security Number
Address
City/State/Zip
Addresses for the Previous 10 Years
NAME OF MOST RECENT EMPLOYER: ___________________________
EMPLOYER PHONE: _________________
EMPLOYER ADDRESS: ______________________________________________________________________________
SIGNATURE: _____________________________
13157644v.2
DATE: _________________________________________________
Rev. 08/2011
11019 McCormick Road, Suite 120, Hunt Valley, MD 21031 • 800-635-1649 • www.PinkertonScreening .com
Name: _________________
PINKERTON
CONSULTING & INVESTIGATIONS
DISCLOSURE AND AUTHORIZATION
[IMPORTANT - PLEASE READ CAREFULLY BEFORE SIGNING
AUTHORIZATION] DISCLOSURE REGARDING BACKGROUND
INVESTIGATION
The Johns Hopkins Hospital Department of Volunteer Services ("The Company1 may obtain information about you for employment
purposes from a third party consumer reporting agency. Thus, you may be the subject of a 'consumer report" and/or an 'investigative
consumer report' which may include information about your character, general reputation, personal characteristics, and/or mode of
living, and which can involve personal interviews with sources such as your neighbors, friends, or associates. These reports may
contain information regarding your credit history, criminal history, social security verification, motor vehicle records ('driving records1,
verification of your education or employment history, or other background-checks. Credit history will only -be requested where such·
information is substantially related to the duties and responsibilities of the position for which you are applying. You have the right,
upon written request made within a reasonable time, to request whether a consumer report has been run about you and disclosure of
the nature and scope of any investigative consumer report and to request a copy of your report. Please be advised that the nature
and scope of.the most common form of investigative consumer report obtained with regard to applicants for employment is an
investigation into your education and/or employment history conducted by Pinkerton Consulting and Investigations, 11019
McCormick Road, Suite 120, Hunt Valley, MD, 800-63&-1649, or another outside organization. The scope of this notice and
authorization is all-encompassing, however, allowing the Company to obtain from any outside organization all manner of consumer
reports and investigative consumer reports now and throughout the course of your employment to the extent permitted by law. As
a·result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any
investigative consumer report.
New York and Maine applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by The Johns
Hopkins Hospital Department of Volunteer Services by contacting the consumer reporting agency identified above directly.You may also contact the Company to
request the name, address and telephone number of the nearest unit of the consumer reporting agency designated to handle inquiries, which the Company shall provide
within 5 days.
New York applicants or employees only: Upon request, you will be informed whether or not a consumer report was requested by The Johns Hopkins Hospital
Department of Volunteer Services, and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the
report. By signing below, you also acknowledge receipt of Article 23-A of the New York Correction Law.
Oregon applicants or employees only: Information describing your rights under federal and Oregon law regarding consumer identity theft protection, the
storage and disposal of your credit information, and remedies available should you suspect or find that the Company has not maintained secured records is
available to you upon request.
Washington State applicants or employees only: You also have the right to request from the consumer reporting agency a written summary of your rights and
remedies under the Washington Fair Credit Reporting Act.
ACKNOWLED MENT ANO AUTHORIZATI ON
I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATI ON and A SUMMARY OF YOUR RIGHTS
UNDER THE FAIR CREDIT
REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of 'consumer
reports' and/or 'investigative consumer reports' by the Company at any time after receipt of this authorization and throughout my
employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or
federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to
furnish any and all background information requested by Pinkerton Consulting and Investigations, 11019 McCormick Road, Suite 120,
Hunt Valley. MD, 800-635-1649, another outside organization acting on behalf of the Company, and/or the Company itself. I agree
that a facsimile ('fax1. electronic or photographic copy of this Authorization shall be as valid as the original.
New York appliants or em11loyees on!)'.: By signing below, you also acknowledge receipt of Article 23-A of the New York Correction
Law.
Minnesota and Oklahoma applicants or employees only: Please check this box if you would like to receive a copy of a consumer
report if one is obtained by the Company.
California applicants or employees only: By signing below, you also acknowledge receipt of the NOTICE REGARDING
BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. Please check this box if you would like to receive a copy of
an investigative consumer report or consumer credit repor1 at no charge if one is obtained by the Company whenever you have a
right to receive such a copy under California law.
Print Name: _________________________________________________
Signature: _________________________________________________
13157644v.2
Date:
_
Rev. 0812011
11019 McCormick Road, Suite 120, Hunt Valley, MD 21031 • 800-635-1649 • www.PinkertonScreening.com