Durango C/V 2015 Coach/Volunteer Registration Form Durango 2015 :: 6/15 thru 6/19Items with an asterisk " * " are REQUIRED. Please have your personal and medical information ready to go, and your credit card ready to pay your camp fee. The fee for Coach/Volunteers is $35, with a $20 background check fee if you are over 18. This fee does not include your lunch. This form's last step links to PayPal where you can pay your fee. 1 Volunteer Information 2 Health and Insurance Information 3 Personal Information 4 Policies and Releases COACH/VOLUNTEER INFORMATION: Coach/Volunteer Name* First Last Have you previously registered as a Coach/Volunteer? No Yes If so, for whch event? (example: Arlington 2013) Best email address to communicate about this Registration?* Please enter email address twice. This technique makes sure you entered it correctly. Thanks! Enter Email Confirm Email Address* Street Address Address Line 2 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific State ZIP Code Send Us a Photo (Browse to a photo on your drive. This will help us know you.) Home Church* Age (at start of Camp)* 13 14 15 16 17 18 or older Current Grade (at start of camp)* T-shirt size?* Adult Small Adult Medium Adult Large Adult XL Adult XXL Sex:* Male Female Other contact(s) Champions might need (please supply at least one contact's information):* Mother Father Both Other Mother's Name First Last Mother's Home Phone Mother's Cell Phone Mother's Employer Mother's Work Phone Mother's Email Address Enter Email Confirm Email Father's Name First Last Father's Home Phone Father's Cell Phone Father's Employer Father's Work Phone Father's Email Address Enter Email Confirm Email Who to contact if an emergency?* Mother Father Both Alternate contact (add information below) Alternate Emergency Contact* Include Name, relationship to Volunteer, and phone contact information... HEALTH AND INSURANCE INFORMATION: Primary Insured Family Member* Employer* Name of Insurance Company* Policy Number* Group Number* Telephone Number on Back of Card* Format = (###)###-#### Medicaid Number (if applicable) Date of Last Tetanus Shot* format = ##-##-#### Do you have any medication allergies?* No Yes Please list/detail any medication allergies: Do you take any medication on a regular basis?* No Yes If yes, what medications? Please explain. Do you have any special skills you'd like to mention (worship leading, vocalist/instrumentalist, photographer, etc.)?* No Yes Please list/explain any special skills you'd like to mention (worship leading, vocalist/instrumentalist, photographer, etc.) PERSONAL INFORMATION Please answer the following questions honestly and thoroughly. Why do you want to work at Champions Day Camp?* Have you ever worked with individuals with Special Needs before?* No Yes Tell us about your experience working with individuals with Special Needs: What 3 words describe you?* Briefly describe your walk with Christ:* POLICIES; HEALTH RELEASE; MEDIA RELEASE Please carefully read each statement below. You'll be asked to initial each section using your mouse or touch screen, and to sign and date the document before you Submit. Medication at Camp Prior to camp, you will receive a medication form. You will be able to provide specific details on how and when to administer medication. The policy regarding medication is as follows: • Keep all medication in its original pharmacy labeled bottle or its original over-the-counter packaging. The medical staff will not dispense any medications not in its original container. This policy includes vitamins and herbs. • Place medication bottle or original over-the-counter package in a labeled Ziploc bag. • Include the medication form in the Ziploc bag with the medication needed for the week. • Bring your medication with the form on the first day of camp. Special Diets If you require a special diet you must bring your own food for lunch and snacks daily. Cell Phone Cell phones are not allowed during camp hours except for emergency situations. During Camp hours your focus should be on your Champion. Using a cell phone will hinder your opportunity to develop a relationship with him or her. Please do not share your cell phone number with your Champion during the week. Difficult situations can arise if your Champion begins to call you repeatedly. If asked, simply say that is is not a good idea to share cell phone numbers. Attire Please wear appropriate clothes for the season of year and the nature of the activity. If wearing shorts, please make sure they are modest length. Please do not wear flip-flops - tennis shoes or secure sandals like Charco's are reuired for camp. Training Upon acceptance, you will be given Training dates and times. if you are unable to attend Training, please notify Alison Gromer (alison @ ChampionsSpecialMinistries.org). Camp schedules and other information that will help prepare you in your volunteer role will be given to you at training time. Volunteer Hours Participation in the Champions program can be used for volunteer service hours.Special Needs Health Center will provide a certificate of service at the end of the program if you request it. Policies - Initial* I have carefully read and understand the above Special Needs Health Center Inc. policies. I agree with the policies and will inform my camper of the rules and policies of camp. (Initial using your mouse or touchscreen.) Release of Liability - Initial* I understand that Special Needs Health Center Inc. is NOT responsible for loss of clothing or personal property while at events. I agree to bring all articles of clothing and personal property clearly marked with my first and last name. I understand that part of the day camp experience involves activities, group social arrangements and interactions. These activities and interactions may come with certain risks or uncertainties, and I am aware of these risks. I realize that no environment is risk-free, and I understand risks are minimized when following the rules as instructed by the camp staff. These rules are made to insure safety for all and I agree to follow all rules. I hereby, and for my heirs, executors, and administrators, assigns and all legal guardians, waive and release any and all rights and claims of any nature I may have against Special Needs Health Center Inc., its directors, collectively and individually, employees, Board of Directors, coaches, campers and cooperating entities for and against any and all injuries and damages of any nature, including death, which I may suffer while taking part in Special Needs Health Center Inc. Day Camp or other activities associated with Special Needs Health Center Inc. I HAVE CAREFULLY READ, UNDERSTAND AND AGREE WITH THE Special Needs Health Center, INC., RELEASE OF LIABILITIES. (Initial using your mouse or touchscreen.) Medical Authorization and Privacy Agreement - Initial* I hereby give permission to the physician selected by the Camp Director to order routine medical tests, X-rays, and treatment for emergency health concerns in the event that the parent/guardian cannot be reached. I give the members of the camp medical team permission to administer over-the-counter medications as needed and to give scheduled medication as ordered on the Medication Instruction Form. I realize the camp has a limited liability medical policy for volunteers with a $2,500 maximum limit, covering only trauma, not illness. Any medical expenses in excess of this amount will be my responsibility. I authorize any physician, nurse or other health care provider to communicate with the camp medical staff and any Director of Special Needs Health Center, or his/her designee, concerning my medical condition, treatment and/or prognosis. I HAVE CAREFULLY READ, UNDERSTAND AND AGREE WITH THE Special Needs Health Center, INC., MEDICAL AUTHORIZATION AND PRIVACY AGREEMENT. (Initial using your mouse or touchscreen.) Media Release - Initial* I realize that photographs and films of camp activities may be taken and used for fund-raising and publicity purposes. I hereby give my consent to Special Needs Health Center Inc., its officers, employees, agents, chapters, assignees, licensees and cooperating entities, to use my picture, name, portrait, likeness, writings or biographical information, and/or audio tape for editorial, educational, promotional and advertising purposes, for the solicitation of contributions and for any other purposes in furtherance of the corporate purposes and objectives of Special Needs Health Center, Inc. This release and consent shall be binding upon my child’s heirs, executors, administrator, assigns, and all legal guardians of my child. I HAVE CAREFULLY READ, UNDERSTAND AND AGREE WITH THE Special Needs Health Center, INC., MEDIA RELEASE. (Initial using your mouse or touchscreen.) Authorization for Background Check (required for Volunteer Staff over 18) INFORMATIONAL: All volunteers age 18 and older on the date Camp starts must complete a separate Background Check Release, authorizing the investigation of any or all statements provided during the process of this application, releasing the organization from all liability for any damages for issuing this information concerning my background. You'll also authorize the investigation of any or all statements provided during the process of this application, and release the organization from all liability for any damages for issuing this information concerning my background records. It's your responsibility to access and complete the Background Check Release form on the Champions web site - - on the menu under Coach/Volunteer; Background Check. Parent/Guardian's Full Signature and Date* I HAVE CAREFULLY READ, UNDERSTAND AND AGREE WITH ALL POLICIES AND STATEMENTS IN THIS Special Needs Health Center, INC., VOLUNTEER REGISTRATION FORM. (Add your signature below with your mouse or touchscreen.) Volunteer's Full Signature* I HAVE CAREFULLY READ, UNDERSTAND AND AGREE WITH ALL POLICIES AND STATEMENTS IN THIS Special Needs Health Center, INC., VOLUNTEER REGISTRATION FORM. (Add your signature below with your mouse or touchscreen.) Today's Date* (Legal Signature requires you to choose today's date.) Pay your fee Pay your Volunteer registration fee with PayPal or any credit card below... Coach/Volunteer Staff 18 and older - Dallas Camp 2015* $35 - plus $20 Background Check fee. It's your responsibility to complete the Background Check Release form; see the web site under Coach/Volunteer; Background Check. Price: $55.00 Coach/Volunteer Staff under 18 - Dallas Camp 2015* $35 Price: $35.00 Total $0.00