Kay's Kamp 2020 New Staff Application

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ALL NEW APPLICANTS MUST BE 20 YEARS OF AGE OR OLDER AND HAVE COMPLETED THE FOLLOWING TO BE CONSIDERED: (JUNIOR COUNSELOR APPLICANTS ARE 19 YEARS OF AGE CURRENTLY IN TREATMENT OR CANCER SURVIVIOR)
     * Filed a completed application
     * Attended a personal interview with the Kamp Director, Staff Directors, or their assistants
     * Had a successful criminal background check
     * Had successful reference checks
     * Attended staff orientation as scheduled
 
Please indicate prefered positon (Counselor or Activity staff)
NOTE:  Positions are filled based on need and availablity.  Every effort will be made to honor your request.  
 
PERSONAL INFORMATION

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.

T-Shirt Size (unisex)
Female Staff Gift Size (not unisex)
Are you CPR certified

 
 
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 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 Administration 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 exercise?
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, rash, hives, acne, etc.)
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? ***All staff are required to provide proof of current MMR vaccine/booster. Fax or email your documentation to Medical Coordination Director, Mary Ellen McKnight at 302-834-0367 or memcknight@kaysfdn.org. This documentation is required for acceptance for the 2020 kamp week.
 (Yes or No)
Tetanus (DTaP, DT, Td or Tdap)
Hepatitis B
MMR (Measles, Mumps, Rubella)
Varicella
2019/2020 Influenza vaccine
If you have had a recent PPD test, please complete the following.
Tuberculin Test, most recent result
Have you or any member of your immediate family traveled outside of the United States within six (6) months of July 2020? *
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 our Medical Coordination Director at: memcknight@kaysfdn.org as soon as possible!
PERSONAL MEDICATIONS
 
Please list all medications (including over-the-counter and non-prescription drugs) taken routinely.  Bring enough medication to last 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
REFERENCES
Please list three (3) people who are not your relatives to serve as references.  Include one (1) former employer (if you have previous work experience) 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.
Pre-Interview Questions (NEW APPLICANTS ONLY)

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. *