2021 Kay's Kamp Medical Day Volunteer Application

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Thank you for your interest in Kay's Kamp - Delaware's only camp for children with cancer.  Kay's Kamp will run Monday, July 26, 2021 through Saturday, July 31st, 2021. This year's kamp will be hybrid, alternating between virtual and small, in-person sessions. Nurses will be needed for a minimum of 2 hours for in-person activities with the potential of 4 hours if kamper transportation is needed. Dates and times for the in-person activities will be determined closer to kamp. 
 
If you have any questions, contact our Medical Coordination Director, Dr. Mary Ellen McKnight at: memcknight@kaysfdn.org.  
Kay’s Foundation/Kay’s Kamp does not and shall not discriminate on the basis of race, color, religion, creed, gender, gender expression, gender identity, age, national origin, disability, marital status, sexual orientation, genetic information, pregnancy, or veteran or military status, in any of its activities or operations. These activities include, but are not limited to, hiring and firing of staff, selection of volunteers and vendors, and provision of services.
 
We are committed to providing an inclusive and welcoming environment for all members of our staff, volunteers, subcontractors, vendors, and participants. We are committed in all areas to providing a work environment that is free from harassment. Harassment of others on the basis of their sex, sexual orientation, age, race, color, national origin, religion, marital or veteran status, citizenship, disability, or other personal characteristics covered by Kay’s Foundation’s non-discrimination policy is strictly prohibited.
Are you a returning Kamp volunteer? *
Position applying for
T-shirt Size (unisex)
Female Staff Gift Size (NOT unisex)
Have you or any member of your immediate family traveled outside of the United States within 30 days of July 26th, 2021? *
COVID-19 Information
This information pertains to the applicant and any family member living in the same household.
 *
 Yes or NoIf yes, dateRelationship to you
Diagnosed with COVID-19
Have you received the COVID-19 vaccine, dose 1?
Have you received the COVID-19 vaccine, dose 2?
SCREENING AND TESTING FOR COVID-19

 *
 Yes or No
Do you agree to being screened for COVID-19?
Do you agree to comply with testing protocols in order to attend in-person kamp activities?
Please list Physician licensure information.
 Also, please include any additional states in which you hold privileges.
License #
State
Expiration
License #
State
Expiration
License #
State
Expiration
Do you carry malpractice insurance coverage? *
Please include a copy of all licenses and certifications with your application (or FAX to: 302-834-0367)
 
***As of 2019, all medical staff are required to provide proof of current MMR vaccine/booster. Please fax or email our Medical Coordination Director, Mary Ellen McKnight, at 302-834-0367 or memcknight@kaysfdn.org.

CPR Certification
Do you have your own private practice?
Have you ever been convicted of a felony or misdemeanor other than minor traffic offenses?
Kay's Kamp policy is to prohibit all forms of harassment by our volunteers. This includes sexual, racial, religious and all other forms of harassment. Have you ever been accused of harassment of any person including, but not limited to, workplace harassment?
NOTE: A prior conviction or accusation is not an automatic bar from volunteering.  The type of conviction or accusation will be evaluated by Kay's Kamp Administration before any decision is made. 

APPLICATION CERTIFICATION & AUTHORIZATION

As the applicant completing this staff application, I hereby certify that the information provided on this form is current, true and correct to the best of my knowledge. I hereby authorize the contact of any references, and I authorize Kay's Kamp to conduct any required criminal background checks. I understand that misrepresentation or omission of information requested is just cause to rescind or terminate any volunteer acceptance. If accepted as a volunteer, I agree to abide by the Kay's Kamp policies and to fulfill my volunteer responsibilities to the best of my abilities.

I hereby authorize Kay's Kamp to obtain information pertaining to any federal and state law violation charges as part of any required background check. The information will include any charges and convictions involving minors, adults or property and will be gathered from any law enforcement agency or any other state or federal government agency to the full extent permitted by law.  I understand that such state and federal background access is for the purpose of considering my application as a volunteer and that I expressly DO NOT authorize the Kay’s Kamp, its directors, officers, employees or other volunteers to disseminate this information in any way to any other individual, group, agency, organization or corporation.

I consent to appear in any photographs and/or videos that may be created for the purpose of obtaining publicity for Kay's Kamp or for providing documented materials to be shared with campers and staff. Such use may include, but shall not be limited to any advertisements, documentation of camp activities, or promotion on television, radio, newspaper, magazine, promotional film, webpage, flier, etc.  I understand there will be no compensation for the use of such materials and that materials so used, shall remain the property of Kay's Foundation. I agree to hold harmless Kay's Foundation, its employees, legal representatives or assigns and all persons acting under their authority from any liability that may arise from publication of such photographs and/or videos.

As a volunteer of Kay's Kamp, I agree that any medical/surgical emergency is my financial responsibility. In the case of a medical and/or surgical emergency, I authorize the Kay's Kamp medical team to render care or arrange for any x-rays, anesthetic, medical, dental, or surgical diagnosis, surgery or treatment and hospital care which is deemed advisable and rendered by any attending licensed physician, dentist or surgeon.

I acknowledge that certain activities at Kay's Kamp may have an increased risk of personal injury. I assume full responsibility for my personal safety and understand that participation in activities is strictly voluntary. I agree to release and indemnify Kay's Kamp, Kay's Foundation, and all of its agents, representatives, employees (paid or voluntary) from any claims, costs, expenses, and/or damages which I may sustain or incur by joining in such activities.

I understand that Kay's Kamp policy is to prohibit all forms of harassment by our staff volunteers. This includes sexual, racial, religious and other forms of harassment. I understand that failure to abide by Kay's Kamp policies is just cause to rescind or terminate any volunteer acceptance.

While I am free to bring personal property items to Kay's Kamp, I understand that Kay's Kamp accepts no responsibility for the loss, damage or theft of any personal property.  Alcohol or tobacco products in any form, illegal drugs, firearms or other weapons are not permitted at Kay’s Kamp and will result in immediate termination.

By checking this block I certify the above application information that I have provided is current, true, and correct and I have read and agree to the foregoing terms and conditions. It also indicates my understanding that any patient names or information I may receive while participating as a volunteer at Kay’s Kamp is confidential information and will be treated as such by me. *