Kay's Kamp 2017 Medical Staff Application

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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.
GENERAL INFORMATION
 
PERSONAL INFORMATION
Gender *
Applicant Position
Level of Education
T-Shirt Size (unisex)
Female staff gift size (not unisex)
Are you CPR certified

 
I would like to volunteer for:
NURSES ONLY - I would like to volunteer to be a firefly nurse (1:1 critical care)
Do you have your own private practice?
Do you carry your own individual malpractice insurance as a supplement to your employers insurance?
If "NO", you will need to verify that you are covered on Kay's Kamp site.
 
 
MEDICAL INSURANCE
Do you currently have medical insurance
EMERGENCY CONTACT INFORMATION
 
BACKGROUND INFORMATION
Have you ever been convicted of a felony or misdemeanor other than minor traffic offenses? *
Have you ever been accused of a a sexual, racial, religious or other form of harassment of any person? *
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 before any decision is made.

MEDICAL INFORMATION
Medical information in this section is gathered to assist us in identifying appropriate care.  Any changes to information contained in this section should be provided to the Kamp health personnel upon your arrival at Kamp.  Please provide complete information so that Kay's Kamp can be aware of your medical status.
 
HAVE YOU/DO YOU:
1. Have any recent injury, illness or infectious disease?
2. Have a chronic or recurring illness/injury?
3. Been hospitalized in the past 18 months?
4. Had surgery in the past 18 months?
5. Have headaches or migraines?
6. Had a head injury?
7. Been knocked unconscious?
8. Wear glasses, contacts or protective eyewear?
9. Passed out during excercise?
10. Been dizzy during or after excercise?
11. Had seizures?
12. Had chest pain during or after excercise?
13. Had high blood pressure?
14. Been diagnosed with a heart murmur?
15. Had back problems?
16. Had problems with joints (knees, ankles, etc.)?
17. Have any skin problems (itching, hives, rash, acne?)
18. Have asthma?
19. Had mononucleosis in the past 12 months?
20. Had problems with diarrhea/constipation?
21. Had problems sleep walking?
22. If female, have abnormal menstrual history?
23. Had an eating disorder?
24. Have ADD/ADHD?
25. Have any mental health issues (depression, anxiety, etc.)?
26. Use any tobacco products (including E-cigarettes)? *
Additional Medical Diagnosis/Surgery History
 Please provide a description of any medical problems not addressed above
Medical Diagnosis & Date
Brief Description
Surgery & Date
Medical Diagnosis & Date
Brief Description
Surgery & Date
Medical Diagnosis & Date
Brief Description
Surgery & Date
ALLERGIES: Please list all known allergies, including medications, food, environmental, insect, hay fever, asthma, etc.  SYMPTOMS/SIDE EFFECTS: Please list side effects including rash, hives, difficulty breathing, shock, etc.
 Allergy toSymptoms/Side Effects
Allergy
Allergy
Allergy
Allergy
Allergy
Are the following immunizations current?
 yes or no
Tetanus (DTaP, DT, Td or Tdap)
Hepatitis B
MMR (Measles, Mumps, Rubella)
Varicella
2015/2016 Influenza vaccine
Tuberculin Test, most recent result
Have you or any member of your immediate family traveled outside the United States in the last six (6) months? *
NOTE! If you have been exposed to any communicable disease, particularly chicken pox (which is especially dangerous to children on chemotherapy), during the month prior to Kamp,
please contact us as soon as possible!
PERSONAL MEDICATIONS
 
Please list all medications (including over-the-counter and non-prescription drugs) taken routinely.  Bring enough medication to ast the entire time at Kamp.  If you are bringing prescription drugs, keep them in the original packaging that identifies the prescribing physician, name of the medication, the dosage and the frequency of administration.

 

APPLICANTS LIMITATIONS
Do you require the use of any special equipment?

FAMILY PHYSICIAN
DENTIST/ORTHODONTIST


 RETURNING STAFF - PLEASE SCROLL DOWN TO CERTIFICATION AND AUTHORIZATION SECTION 


NEW MEDICAL APPLICANTS ONLY

ALL NEW APPLICANTS MUST BE 21 YEARS OF AGE AND OLDER AND HAVE COMPLETED THE FOLLOWING TO BE CONSIDERED:
     * Filed a completed application
     * Attended a personal interview with the Staff. Kamp, Medical Directors, or their assistants
     * Had a successful criminal background check
     * Had successful reference checks
     * Attended staff orientation as scheduled
 
For all first time applicants, please list three (3) people who are not your relatives to serve as references.  Please include one (1) former employer and two (2) people that can attest to your character and ability to work in different  situations. 
 
NOTE: Remember when listing a reference that they need to be readily available for contact by Kay's Kamp staff.  If we are unable to reach a reference, you will be required to provide an additional name.
APPLICANT EXPERIENCE (NEW APPLICANTS ONLY)

APPLICATION CERTIFICATION & AUTHORIZATION (ALL APPLICANTS)

As the person completing this staff application, I hereby certify that the application 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 a criminal background check on myself. I understand that the misrepresentation or omission of information requested is just cause for non-appointment, termination, or disengagement as a volunteer. If accepted as a volunteer, I agree to abide by the standards of Kay's Kamp and to fulfill my volunteer responsibilities to the best of my abilities.

I hereby authorize Kay's Kamp to obtain information pertaining to any charges I may have for federal and state criminal law violations as part of a routine background check. The information will include convictions committed upon minors and adults and will be gathered from any law enforcement agency of this state or any other state or federal government to the full extent permitted by law.

I understand that such state and federal access is for the purpose of considering my application as a volunteer and that I expressly DO NOT authorize the 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 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 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 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.

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 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 physician.

I understand that Kay's Kamp policy is to prohibit all forms of harassment by our 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 for nonappointment, termination or disengagement as a volunteer.

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 of my personal property.

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. *