Download Camp Sunrise SubSibs Camp Volunteer Application

January 5, 2016
Dear Prospective SunSibs Staff,
Thank you for your interest in being a member of the 2016 SunSibs staff. We are very excited for
SunSibs Spaced Out this year. SunSibs will be held May 27-30, 2016 at Camp Puh'tok in
Monkton, Maryland.
The Department of Volunteer Services of The Johns Hopkins Hospital will be handling all
SunSibs applications again this year. All staff must submit references. In addition to the
references, fingerprinting is required for all new staff members. Please go to your local CJIS
office to get fingerprints completed. The account number needed is 1000001995.
In the past, returning staff have been able to submit their applications past the due date and still
attend camp. This will no longer be the case. All SunSibs staff applications are due NO LATER
than Saturday March 5, 2016. If your application is turned in after this time, even for returning
staff, you will not be considered for a position at camp (NO EXCEPTIONS).
Enclosed you will find information listing requirements needed to become a SunSibs Volunteer.
When completing the application, you can either email your completed application to
[email protected] or send the completed application to:
Johns Hopkins Sun Sibs
C/O Tommy Beam
PO Box 470
Hanover, PA 17331
Once we have received your application, the Department of Volunteer Services will process your
information. The Staff Director will contact new staff to schedule an interview. Once you have
secured a staff position, you must attend camp orientation on May 27, 2016. During orientation,
you will learn about the history of Camp Sunrise and SunSibs, and go over camp policies and
procedures. This is mandatory for all returning and new staff! We will send out more
information as we approach camp.
We are also recruiting new volunteers. Please tell a friend about this wonderful program. For
additional applications, contact the staff director or visit www.hopkinsmedicine.org/campsunrise.
We are looking forward to seeing you at SunSibs Spaced Out 2016!
Sincerely,
Tommy Beam
Staff Director
[email protected]
Kasey Carroll
Camp Director
[email protected]
Volunteer Application
Johns Hopkins University
Pediatric Oncology
May 27nd-30th 2016
Due March 5, 2016
General Information (please print)
Name: _______________________________________ Male ______ Female ______
Address: _____________________________________ E-mail:__________________
City: __________________________ State: ______________ Zip: _______________
Home Phone: (_____) _________________ Work Phone: (_____) ________________
Cell 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? __________________________________________
Are you interested in applying for Camp Sunrise 2016? (July 30-August 6) _____________
What position are you applying for?:
Camp Counselor Staff
Program/Activities Staff
If camp counselor which age group do you prefer?________________________________________
Please check the activities you would be comfortable leading.
Campfire programs
Story Telling
Ropes Course
Arts & Crafts
Archery
Team Sports
Nature
Photography
Music/Singing
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 (All information will be held confidential, unless specified otherwise).
Please attach a copy of your driver’s license
Name: ________________
Employment & Volunteer History
Present employer:
Employer’s name: ______________________________________________________
Your position: _________________________________________________________
Address: ________________________________ Phone: (_____) ________________
Supervisor’s name: ______________________ Employed since: ________________
Volunteer Experience (Most recent):
Position:_________________________ Agency:_________________
Date(s):______________
Position:_________________________ Agency:_________________
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: No Experience
Some Experience
A lot of Experience
Please describe:
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:_____________________________ Telephone number:___________ E-mail:____________
Street Address:______________________________ City:_____________ State/Zip:___________
Name:____________________________ Telephone number:___________ E-mail:____________
Street Address:______________________________ City:_____________ State/Zip:___________
SunSibs Volunteer Application: Page 2 of 6
Name: ________________
Agreement to take part in SunSibs Overnight activities:
I want to take part in all SunSibs 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, SunSibs 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 SunSibs 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 SunSibs. 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 Staff ________________________________
Permission to complete attitude surveys and program evaluation surveys:
I agree to anonymously fill out attitude and program evaluation surveys during SunSibs programming.
Information from surveys will be used to evaluate the program and for educational or teaching purposes.
YES ______
NO______
Signature of Volunteer Staff_______________________________
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: _____________________________________ 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 SunSibs is confidential information and will be treated as such by me.
Signature: _____________________________________ Date: __________________
Permission to include contact information in SunSibs Alumni & Staff Directory
I give my permission to include contact information about me in the SunSibs Alumni & Staff directory which will
be distributed to program participants.
YES ______
NO______
Signature _____________________________________
SunSibs Volunteer Application: Page 3 of 6
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.
SunSibs Volunteer Application: Page 4 of 6
Name: ________________
In order to volunteer for SunSibs 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 SunSibs.
NEW and RETURNING
SunSibs Volunteer
*****You WILL need to provide
recent PPD results
Employee at Johns Hopkins
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
May 1, 2016
Documentation of a negative PPD
obtained after
May 1, 2016
SunSibs Volunteer Application: Page 5 of 6
Name: ________________
General Health History
LAST EAR INFECTION (Date) ____________________
HEART PROBLEMS
 YES NO
MUMPS
SEIZURES
YES NO
MEASLES
DIABETES
YES NO
GERMAN MEASLES
ASTHMA
YES NO
YES
YES
YES
IMMUNIZATION HISTORY: (All immunizations must be kept up to date.)
DPT SERIES
__________ LAST TETANUS BOOSTER
BOOSTER
__________ LAST TUBERCULIN TEST
POLIO BOOSTER
__________ OTHER
MMR (MEASLES, MUMPS, RUBELLA) __________
__________
__________
__________
NO
NO
NO
ANY RECENT/CURRENT INFECTIOUS/COMMUNICABLE DISEASE EXPOSURE?
(PLEASE EXPLAIN): _________________________________________________
ALLERGIES TO:
HAY FEVER
 YES  NO
INSECT STINGS
 YES
 NO
IVY POISONING
 YES  NO
MEDICATIONS
 YES  NO
OTHER ______________________________________________________________________
RECOMMENDATIONS/RESTRICTIONS:
DIET:
________________________________________________________________________________
SWIMMING/DIVING:
________________________________________________________________________________
ACTIVITY LEVEL:
________________________________________________________________________________
OTHER:
________________________________________________________________________________
MEDICATIONS: MEDICATIONS MUST BE BROUGHT IN ORIGINAL PHARMACY CONTAINERS
DRUG
DOSE
TIME
SunSibs Volunteer Application: Page 6 of 6
DAYS OF WEEK
DISCLOSURE AND AUTHORIZATION
[IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION]
DISCLOSURE REGARDING BACKGROUND INVESTIGATION
The Johns Hopkins Hospital Department of Volunteer Services (“The Company”) 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 records”), 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, 800-635-1649, 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.
ACKNOWLEDGMENT AND AUTHORIZATION
I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION 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 (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.
New York applicants or employees only: 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 report 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:______
1
11019 McCormick Road, Suite 120, Hunt Valley, MD 21031
____
Rev. 08/2011
y
800-635-1649
y
www.PinkertonScreening.com
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
Street Address
City/County
State
Zip Code
Dates of Residency
From – To
-----------
NAME OF MOST RECENT EMPLOYER ______________________________________________ EMPLOYER PHONE _________________
EMPLOYER
ADDRESS________________________________________________________________________________________________
SIGNATURE __________________________________________ DATE __________________________
13157644v.2
1
11019 McCormick Road, Suite 120, Hunt Valley, MD 21031
Rev. 08/2011
y
800-635-1649
y
www.PinkertonScreening.com