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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