2017 Kay's Kamp Medical Day Volunteer Application Volunteering TWO (2) Days or less ONLY

Form Login Account (optional)
New Users / Returning Users CLICK HERE to setup or return to your account for this form. Creating an account enables you to return to this form and your submitted results. An account will also enable you to partially complete this form and return later to finish the form. The account you establish is only for this form.
Thank you for your interest in Kay's Kamp - Delaware's only camp for children with cancer.  Kay's Kamp will run Saturday, July 22, 2017 (staff orientation) through Saturday, July 29, 2017.  The kampers will arrive Sunday, July 23rd.  If you will be volunteering for two (2) days or less, please complete this abbreviated medical application for the 2017 Kamp session.  Make sure you sign all required areas.
 
Once we receive your completed application, it will be reviewed and you will be contacted regarding your availability.   If you have any questions please contact the Medical Coordination Director, Mary Ellen McKnight at: memcknight@kewf.org
Gender *
Are you a returning Kamp volunteer? *
Position applying for
T-shirt Size (unisex)
Female Staff Gift Size (NOT unisex)
I would like to volunteer for
Preferred Shift
Have you or any member of your immediate family traveled outside of the United States within six (6) months of July 2017? *
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: 302-836-8534)

 
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. 

AUTHORIZATION TO PERFORM CRIMINAL BACKGROUND CHECK
 
I hereby authorize Kay's Kamp to obtain information pertaining to any charges I may have for federal and state criminal law violations.  This information will include convictions commiteed upon minor and adults and will be gathered from any law enforcememt agency of this state or any other state or federal government to the full etnet permitted by law.
 
I underatand that such access is for the purpose of considering my application as a volunteer and that I expressly DO NOT authorize the Kamp, it's directors, officers, employeers or other volunteers to disseminate this information in any way to any other individual, group, agency, organization, or corporation.
 
PHOTOGRAPHIC AND VIDEO CONSENT

I consent that photographic and/or video pictures may be taken for the purpose of obtaining publicity for Kay’s Kamp or for providing documented materials to be shared with kampers and staff. Such use may include, but shall not be limited to any advertisements, documentation of Kamp 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 the Kaylyn Elaine Warren Foundation. I agree to hold harmless the Kaylyn Elaine Warren Foundation, its employees, legal representatives or assigns and all persons acting under their authority from any liability that may arise from publication of such photographic and/or video material.

AUTHORIZATION FOR MEDICAL TREATMENT 

As a volunteer of Kay’s Kamp, I agree that any medical/surgical emergency is my financial responsibility.

 In 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 to and is under the supervision of any duly licensed physician, dentist or surgeon.

 I acknowledge that certain activities at Kay’s Kamp may have an increased risk of injury. I assume full responsibility of my safety. I agree to release and indemnify Kay’s Kamp, the Kaylyn Elaine Warren 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, unless restrictions for such activities are noted by myself or my physicians.

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. *