Please check the program(s) you are interested in volunteering for:
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*Date of Birth:
*Current Age (Must Be 18 Years Of Age or Older)
Emergency Contact Information:
Health Care Provider Information:
*Institution / Hospital where you recieve care:
*Name Of Physician / Nurse Practitioner:
*Physician / Nurse Practitioner Phone:
Do you carry Medical/Health Insurance?
If Yes, Carrier:
Group Policy #:
Employer / Education Information:
Employer / School:
Position / Last Grade or Degree Completed:
*MANDATORY BIOGRAPHY: New York State Health Department and the American Camping Association require ALL applicants to enclose a biography. We need to know about you, your experience with Camp Good Days and Special Times, its programs, or anything that relates to your dealing with children who have special needs. Please include information on areas of expertise, your current certifications (First Aid, CPR, Aquatics), or any physical disabilities you may have.
*Brief Biography of max. 500 words
*REFERENCES: Please list names, complete mailing or email addresses and phone numbers of three persons (not relatives) who have knowledge of your character, experience and abilities.
Photo / Audio-Visual / Media Release:
I hereby grant permission to participate in any audio-visual event (including photos and videos for future Camp use) that may take place in regard to this program and release Camp Good Days and Special Times, Inc., and everyone involved of any liability or claims in association with the media coverage if such takes place.
*(If NO, Please be aware of the responsibility)
Please Read And Verify Below:
I am aware that in being accepted as a volunteer, I am committed to complete MANDATORY TRAININGS, the dates of which are to be announced. The information provided by me in the volunteer application is true and complete to the best of my knowledge. I understand that if I am selected, any false statements will be considered as cause for possible dismissal. You are hereby authorized to conduct any investigation of my personal history, as related to the volunteer position for which I have applied.
Consent for Medical Treatment:
I hereby grant permission to the medical staff at Camp to administer routine and any emergency care required to myself in the event of an emergency.
Permission Slip / Waiver:
I hereby grant permission to participate in the 2016-2017 Camp Good Days and Special Times, Inc. camping programs, as well as monthly programs.
I hereby waive and release Camp Good Days and Special Times, Inc. and everyone involved of any liability or claim in association with anything that might occur to me while attending this program.
I understand that each camper's parent has signed a photo / audio-visual / media release and I will be notified by the Special Needs List if a parent does not wish for their child to be photographed.
As a volunteer of Camp Good Days and Special Times, I understand the sensitivity of the diagnosis and prognosis of each camper and/or their family member. With full understanding of the need for confidentiality and privacy for all program members, I accept the following rules:
1) I will not disclose the name or contact information of any campers to sources outside of Camp Good Days and Special Times
2) I will not disclose any specific medical information about a camper to sources outside of Camp Good Days and Special Times
3) Personal information shared with me by a camper will not be shared or used outside the context of Camp Good Days and Special Times
4) Any information disclosed to me that causes concern or I have questions about can be directed to the Camp Coordinators and/or Staff of Camp Good Days and Special Times
*I verify that I have read, understand, and agree to the statements written above.