Staff Application - Hemophilia Association of San Diego County
April 10, 2015 Dear Prospective Camp Pascucci Staff Member, You have been chosen to join our tribe. This year’s camp theme is Survivor. Grab your buffs and make your way to the mountains for HASDC’s Camp Pascucci as we outwit, outplay and outlast. Our camp is specially designed for youth ages 7-14 with a bleeding disorder, diagnosed carriers and siblings. Camp will be held June 15-20, 2015 at YMCA Camp Whittle in Big Bear (about 2 hours from San Diego). Enclosed you will find the 2015 Camp Pascucci Staff Application. All camp positions are unpaid and voluntary. Please complete the enclosed forms and return them to the Hemophilia Association of San Diego County (HASDC) no later than Friday, May 15, 2015. Please note that staff members with a bleeding disorder must submit a physical. The Physician’s Form must be completed by a hematologist. As it can sometimes take several weeks to get an appointment with a doctor, please do not wait until the last minute to schedule an appointment with your physician. Staff space is limited, therefore it is important to please submit your application by the deadline. If we do not receive your completed application on or before May 15, 2015, you will not be considered as camp staff during our 2015 camping season. Once your application is received, you will receive an email from HireRight with directions for a background check. The background check is required to be considered for a camp staff position. HASDC will contact you by May 31st to inform you of your acceptance as a Camp Pascucci staff member, pending our required background check. The acceptance packet will then be mailed, containing additional information regarding camp check-in times, location, transportation, etc. Please note: staff training will take place Sunday, June 14 and is mandatory for all staff members. If you have any questions prior to the camp start date, please call the office. In the end, only one team will remain to claim the ultimate prize, the title of sole SURVIVOR. We look forward to having you participate in our 2015 camping season. Sincerely, Nooshin Kosar Executive Director 3550 Camino Del Rio North, Suite 105San Diego, CA 92108PH: 619.325.3570FAX: 619.325.4350www.hasdc.org STAFF TRAINING & REGISTRATION MATERIALS Self-Assessment Can you take the time to make a difference? Mandatory staff arrival and training: Sunday, June 14, 2015 Camp Pascucci: Monday, June 15 - Saturday, June 20, 2015. Since you are inquiring about a staff position with Camp Pascucci, it means that you possess a caring and compassionate nature. All camp positions require a significant commitment outside of camp. Sometimes staff with good intentions and great ideas are simply too busy to follow through on their commitment. This can result in a disappointed camper. With this in mind, we are counting on you to follow through with the commitments you make to the camp in addition to the other commitments in your life. You understand that you will check your personal life upon arrival and fully participate in camp for the entire week. You understand that there will be no cell coverage/usage, no access to email, limited sleep and plenty of singing! Please consider this carefully before you apply. Can you go with the flow? The physical environment in which we live at camp is different than what we are used to in our everyday lives. In addition to the uniqueness of the physical environment, we continually challenge camp staff to reach new heights of personal growth that will then help them lead campers to the best possible camp experience. Though this unique environment can be challenging, it is part of what makes it such a rewarding experience for staff. Can you go the extra mile? At Camp Pascucci, we strive to make camp a life-enriching experience for all who attend, campers and staff alike. We strongly urge staff to spend time before camp honing their counseling skills by learning new camp songs, child management techniques, leadership skills, and technical skills. To what length are you willing to go in order to be the best camp counselor, JRC, or general staff person that you can be? Thanks for considering these important questions! Every staff person is important to the mission of Camp Pascucci and the campers rely on YOU for this extraordinary experience. If after answering these questions to yourself, camp seems like it is a good fit for you, then please complete the registration materials. Camp Registration Materials Please return the following items by May 15: 1. Staff Application 2. Medical History 3. Consent Form 4. YMCA Liability & Indemnity Agreement 5. Camp Rules 6. Physician’s Form – for persons with bleeding disorders ONLY, completed by applicant’s hematologist For identification purposes, please Staff Application 2015 attach your photo Camper Pascucci here. IS THIS YOUR FIRST TIME AT CAMP? YES NO IF THIS IS YOUR FIRST TIME, HOW DID YOU HEAR ABOUT US? ____________________________________ APPLICANT’S AREA OF INTEREST (check which position(s) you are interested in): Detailed position descriptions can be found at the end of the application. □ Senior Camper (15 years) □ Co-Director (18+) □ Junior Counselor (16 - 17 years) □ General Volunteer (15+) □ Counselor (18+) □ Medical Staff Applicant General Information Applicant’s Name: _________________________ ________________________ FIRST Gender: □ Male □ Female LAST Address: ____________________________________ City: ___________________ State: ____ Zip: _________ Home Phone: ________________________________ Cell Phone: ________________________________ Email: ____________________________________________________________________________________ Date of Birth: _____ /_____ /_____ Age (as of June ‘15): ______ Highest Level of Education: _________ Employer: _______________________________ Position: _______________________ Phone: ____________ Parent/Guardian Information (if under 18) First Name Address (if different from above) Parent/Guardian #1 Home Phone ( ) Employer First Name Address (if different from above) Parent/Guardian #2 Home Phone ( ) Employer Last Name Relationship to Applicant City State/Zip Cell Phone ( ) Last Name Evening Phone ( ) Work Phone ( ) Relationship to Applicant City State/Zip Cell Phone ( ) Evening Phone ( ) Work Phone ( ) Application Pg. 1 Applicant lives with: □ Both Parents □ Mother □ Father □ Other: ___________________ Emergency Contact Information Emergency Contact #1 Emergency Contact #2 First Name Last Name Relationship to Applicant Address (if different from above) City State/Zip Home Phone ( ) Employer Cell Phone ( ) First Name Last Name Evening Phone ( ) Work Phone ( ) Relationship to Applicant Address (if different from above) City State/Zip Home Phone ( ) Employer Cell Phone ( ) Evening Phone ( ) Work Phone ( ) Employment History Most Recent/Current Job Company/Employer: ________________________________________________________________________ Start Date: __________________________________ End Date: _________________________________ Employer: _____________________________ Position: _____________ Supervisor: ____________________ Work Address: ______________________________ City: _________________ State: ______ Zip: _________ Phone: ____________________________________ Prior Job Company/Employer: ________________________________________________________________________ Start Date: __________________________________ End Date: _________________________________ Employer: _____________________________ Position: _____________ Supervisor: ____________________ Work Address: ______________________________ City: _________________ State: ______ Zip: _________ Phone: ____________________________________ Application Pg. 2 Volunteer/Childcare Experience Have you had previous volunteer or childcare experience? □ Yes □ No If yes, please use the space below to describe. Provide the name of the organization along with your supervisor, relevant dates and the position held. Organization: _____________________________________ Position: __________________________________ Supervisor’s Name: ____________________________ Duration: ____________ Phone: ___________________ References Do not list current employers, relatives or HASDC staff as references. Suggested references include past employers, co-workers, fellow volunteers, babysitting employers, etc. If you are a returning volunteer to Camp Pascucci, you are welcome to list a fellow volunteer of a prior camp as only one of the three references required. Please note: references will be contacted therefore please verify that contact information is current. Reference #1 First Name Last Name Relationship to Applicant Address (if different from above) City State/Zip Home Phone ( ) Employer Cell Phone ( ) First Name Last Name Evening Phone ( ) Work Phone ( ) Relationship to Applicant Address (if different from above) City State/Zip Home Phone ( ) Employer Cell Phone ( ) Evening Phone ( ) Work Phone ( ) Reference #2 Application Pg. 3 Sibling/Relative Also Attending Camp First & Last Name Age Relationship to Applicant Transportation Please choose a drop off location where you will be dropped off to go to camp as well as a pick-up after camp location where you will be picked up at the end of the camping week. You will receive the drop off and pick-up times for your selected locations in your acceptance packet. Drop-off for Staff Training (Sunday, June 14) Pick-up after camp (Saturday, June 20) □ HASDC Office □ HASDC Office □ YMCA Camp Whittle (Big Bear) □ YMCA Camp Whittle (Big Bear) T-Shirt Size (check only one box) Youth Size: □ Large Adult Size: □ Small □ Medium □ Large □ X-Large □ XX-Large Counseling Preference (if applicable) Please indicate which age group(s) you think you would work best with/prefer to work with. □ 7-8 year olds □ 9-10 year olds □ 11-12 year olds □ 13-14 year olds □ 15 year olds Certifications/Trainings Completed CPR Certified: First Aid Training: Lifeguard: □ Yes □ Yes □ Yes □ No □ No □ No Date of Certification: _____________________ Date of Certification: _____________________ Certificate Number: ____________ Exp Date: _______________ Medical Staff Only Type of Licensed Medical Professional: _________________________________________________________ License Number: _________________ State Where Licensed: _______ License Expiration Date: ___________ Application Pg. 4 MEDICAL HISTORY (COMPLETED BY PARENT/GUARDIAN IF UNDER 18) Applicant’s Name: __________________________________________________________________________ Date of Birth: ______ /______ /______ Height: ____________ Weight: ____________ Hemophilia Treatment Center/Physician Information Hematologist Pediatrician/Physician HTC Institution Address Address City State Zip City Phone ( ) □ Unaffected Applicant (leave above blank) State Zip Phone ( ) Diagnosis Factor Deficiency □ Factor 8 □ vWD2b □ Factor 9 □ vWD2c □ vWD1 □ Carrier 8 □ vWD2 □ Carrier 9 □ vWD2a □ Other: _____________________ Severity □ Mild □ Moderate □ Severe Inhibitor □ Yes □ No □ Date of last inhibitor test ______ /______ /______ Treatment Do you/child self-infuse? □ Yes (independently) □ Yes (needs help) Do we have permission to teach your child (if under 18) to self-infuse? □ No (but would like to learn) □ Yes □ No Factor Name: _______________________ Are you/child on prophylaxis? □ Yes □ No If yes, please indicate dosage schedule for camp: Mon:______ Units Tues:______ Units Wed:______ Units Thur:______ Units Fri:______ Units Sat:______ Units If no, please indicate dosage of factor and send enough for at least 3 days of a major bleed Dosage: _________________ Medical History Pg. 1 Other Medical Conditions □ ADD/ADHD □ Heart Defect □ Allergies □ Epilepsy/Seizures □ Asthma □ Diabetes □ Bedwetting □ Trouble Sleeping □ Head lice recently □ Other: _________________ Allergies Drug allergy: ________________ Type of Reaction: ________________ Treatment: ______________________ Drug allergy: ________________ Type of Reaction: ________________ Treatment: ______________________ Food allergy: ________________ Type of Reaction: ________________ Treatment: ______________________ Food allergy: ________________ Type of Reaction: ________________ Treatment: ______________________ Behavioral Concerns □ Shyness □ Psychological □ Anger Management □ Other: ___________________ Medications All medications administered at camp (including over the counter and vitamins) must appear on your medical form. Please send all medications necessary for the week in their original bottles. We will NOT accept pill boxes or any medication not in their original packaging. Camp medical staff will store and administer medications as directed by you. This includes any allergy medications, vitamins, ibuprofen, etc. Medication Dose Mon Tue Wed Thur Fri Sat □ as needed □ as needed □ as needed □ as needed Medical History Pg. 2 Immunizations Please note: All campers/staff must be fully vaccinated to attend Camp Pascucci. Complete or include a copy of immunization records. Immunization Chicken Pox (Varicella) DTaP Hepatitis A Hepatitis B HPV Influenza MMR Meningococcal Pneumococcal Polio Rotavirus Tdap □ Dose 1 □ Dose 1 □ Dose 1 □ Dose 1 □ Dose 1 □ Dose 1 □ Dose 1 □ Dose 1 □ Dose 1 □ Dose 1 □ Dose 1 □ Dose 1 Schedule □ Dose 2 □ Dose 2 □ Dose 3 □ Dose 4 □ Dose 2 □ Dose 2 □ Dose 3 □ Dose 2 □ Dose 3 □ Dose 2 □ Dose 2 □ Dose 2 □ Dose 2 □ Dose 2 Date Completed □ Dose 3 □ Dose 4 □ Dose 3 □ Dose 4 Additional Questions Does you/child know how to swim? □ Yes □ No Does you/child use a wheel chair? □ Yes □ No Does you/child have any dietary restrictions? □ Yes □ No □ if yes, please list: ____________________________________________________________________ Have you/child ever been away from home? □ Yes □ No Have you/child experienced any stressful life events in the past year? □ Yes □ No □ if yes, please explain: _________________________________________________________________ Have you/child ever seen a therapist or psychiatrist? □ Yes □ No □ if yes, please explain: _________________________________________________________________ Insurance □ Check here if you/your child does not have insurance If you have health and accident insurance coverage, please provide the following information: Name of Insurance Company: ______________________________ Insurance Company phone: ________________________________ Policy Number: ________________________ Certificate Number: ________________________ CCS Number: __________________________ MediCal Number: __________________________ Medical History Pg. 3 CONESENT FORM (COMPLETED BY PARENT/GUARDIAN IF UNDER 18) Infusion Instruction Consent (for bleeders, carriers & siblings) At Camp, we will be offering self-infusion classes to campers and staff, carriers and siblings on a voluntary and individual basis by our medical staff. You/child could receive this important training when he/she needs factor replacement during camp, but only if you/child are voluntarily ready to infuse himself, herself or sibling. My signature below indicates my consent/consent for my child to receive infusion instruction. Applicant/Guardian (if under 18) Signature: ___________________________________ Date: ______________ Factor Usage Consent I want my child to use only physician-designated factor while at Camp, and I will be responsible for supplying an adequate amount of factor for the week of Camp. I understand that every reasonable effort will be made to give my child only his/her designated factor. However, I realize the possibility exists that an unusual medical emergency or situation may require that my child use donated factor, which may not be the same brand, purity or assay, and may be a plasma-derived (non-recombinant) product. If this situation occurs, I understand Camp medical staff will authorize the appropriate factor usage, which will be fully documented in my child’s medical log. I hereby release HASDC, YMCA Camp Whittle and their respective agents, employees and representatives from any claim whatsoever as a result of providing donated factor during camp. □ Check here if not applicable (meaning that you/child do not have a bleeding disorder) My signature below indicates my consent for myself/child to receive donated factor during camp. Parent/Guardian (if under 18) Signature: _______________________________________ Date: ____________ Permission to take photographs I hereby give consent for photographs and/or motion pictures of myself/child to be used for any of the following purposes: HASDC publicity, public service announcements on television or the internet, publicity with supporting agencies, scholarship awards, camp promotion or any other agency-approved and supported activity. My signature below indicates my consent for HASDC to use photographs of myself/child taken at camp. Applicant/Guardian (if under 18) Signature: ____________________________________ Date: _____________ Luggage Search I agree that my/child’s belongings may be searched outside the applicant’s presence for electronics, food, candy, drugs, alcohol, weapons or other forbidden objects if there is suspicion of objects being present. My signature below indicates my consent for myself/child’s luggage to be searched if necessary. Parent/Guardian (if under 18) Signature: _______________________________________ Date: _____________ Consent Form Pg. 1 CONFIDENTIALITY AGREEMENT Initial ______ I will respect the confidentiality of the participants and will not use any access I may have to their names, addresses, telephone, e-mail, etc. for personal gain now or at any time in the future. HASDC Camp Procedures/Guidelines The Executive Director of the Hemophilia Association of San Diego County shall appoint Camp Directors at his/her discretion, who will be responsible for all staff, personnel and volunteers while at camp. Applicants understand that space is limited and therefore not everyone will be chosen. All camp volunteers and personnel will be chosen and approved by HASDC staff. All volunteers must pass a background check, an interview and provide three individual references. If there is any dispute at the camp, it shall be resolved at the discretion of the Camp Directors. There will be one person appointed as Chief Medical Staff In-Charge at all times during the camp week. There will be no access to electronic devices such as cell phones and laptops. If you do bring electronic devices they will be held for you by the Camp Directors and returned at the end of the week. There will be no pictures taken by camp volunteer staff. HASDC will take care of photography and post all photos on our website and Facebook page. Camp staff are not allowed to friend campers on Facebook. If this occurs, it can affect your attendance in the future. The use of Camp Pascucci materials including but not limited to camp logo, photographs, articles from its newsletter(s), event fliers, and its website – are expressly prohibited without advance written approval (electronic mail and faxes are acceptable) from Camp Pascucci. Any person or persons who refuse to abide by the guidelines set forth (including rules, regulations, procedures, mission, philosophy, etc.) will be asked to leave the Camp. Initial ______ I have read and agree to comply with the following summer camp procedures listed above. I understand I will be asked to leave camp if I do not honor my agreement. Consent Form Pg. 2 Release of Liability & Authorization for Emergency Medical/Dental Treatment I, __________________________________, am the parent/ legal guardian of a camper, counselor-in-training, or junior counselor (if under 18 years old), or a participant (over 18 years old) who will travel to and attend Camp Pascucci (hereinafter the Camp), at YMCA Camp Whittle, sponsored by the Hemophilia Association of San Diego County. I understand that the activities involved in Camp will pose the risk of harm or injury. On my own behalf, and on behalf of my child or ward, I hereby freely and expressly consent to release, discharge, indemnify and hold harmless, YMCA Camp Whittle, the Hemophilia Association of San Diego County, and their respective agents, employees, and representatives from any damage, claims, loss, or injury sustained by me or my child/ward while traveling to or from the Camp, while attending or participating in any activities at Camp, or any other trips or activities sponsored by the Hemophilia Association of San Diego County. This release includes within its scope any damage, loss or injury sustained as a result of any ordinary negligence, whether active or passive on the part of YMCA Camp Whittle, the Hemophilia Association of San Diego County, or any of their respective agents, employees or representatives. As the parent/guardian of the camper, counselor-in-training, junior counselor, or as a participant, I hereby give my consent to any medical treatment, including any examination, X-ray, anesthetic, medical or surgical diagnosis or treatment, or hospital care to be rendered to me or my child/ward under the general or special provisions of the Medical Practice Act, or to consent to any dental treatment, including any examination, X-ray, anesthetic, dental or surgical diagnosis or treatment, or hospital care to be rendered to me or my child/ward by a dentist licensed under the provisions of the Dental Practice Act. This authorization shall be effective while I or my child/ward is en-route to or from Camp, or involved or participating in any program or activity of Camp, or under the supervision of any personnel associated with the Camp, regardless of the location where treatment or care is rendered, unless earlier revoked by me in writing and delivered to the Camp Director. The foregoing release is to be construed in accordance with the laws of the State of California. It is intended to release claims which are not yet known. Accordingly, I hereby waive, on my own behalf, and on behalf of my child/ward, the provisions of California Civil Code §1542, which provides: “A general release does not extend to claims which the creditor does not know or suspect to exist in his favor at the time of executing the release, which if known by him must have materially affected his settlement with the debtor.” I have read and understood this Release and Authorization and the attached Medical History and Information Form, and the information I have given is true and correct. PHOTOSTATIC COPIES OF THIS RELEASE AND AUTHORIZATION WILL BE CONSIDERED AS VALID AS THE ORIGINAL. Signature (parent/guardian/participant if over 18): __________________________________ Date: _________ Print name: ____________________________________ Applicant Name: _____________________________ Consent Form Pg. 3 YMCA CAMP WHITTLE Liability & Indemnity Agreement YMCA Liability Form Pg. 1 CAMP RULES Please be sure that you know and agree to the following camp rules before coming to camp. All campers and staff must abide by camp rules for the duration of the camping week. Campers and staff not following camp rules may be asked to leave camp and transportation must be provided by applicant/parent or guardian. GENERAL DO NOT bring food, candy or drinks with you. If found, items will be confiscated. Electronic equipment of any kind (handheld games, MP3 players, TV’s, Stereos, Cell Phones, etc.) are prohibited at camp. Camp staff will confiscate them. Parents, please keep these items at home! Wear shoes at all times. NO SANDALS OR OPEN TOED SHOES AT CAMP! Throwing rocks (or any object) could injure someone – don’t throw anything at camp. No weapons (knives, guns, sling-shots, other weapons, etc.) are ever allowed at camp at any time. You must be accompanied by a staff person at all times. Follow the buddy system – you should ALWAYS have a buddy with you. You must stay on the camp grounds at all times. Leaving is not permitted. No water balloons as they can cause injuries – water games take place in an organized fashion or at the pool only. No visitors are allowed at any time, without expressing prior permission from our Camp Director. CABIN RULES Stay with your cabin group. Get permission from a counselor before entering another cabin. Respect the space and property of others – stay out of other campers’ belongings. Graffiti (carved or written) is vandalism. We (you) will pay for all damages to camp property. Counselors and campers will jointly make up additional rules for their cabins– follow these! RESPECT Observe the A. D. S. rules at camp – NO Alcohol, NO Drugs, NO Sex at Camp. EVER. This is a non-smoking camp. No smoking is allowed anywhere on camp grounds. Please treat all campers and staff with respect. Teasing, swearing, inappropriate jokes and rude behavior are unacceptable - inappropriate behavior will result in contacting camper’s parent/guardian. ENVIRONMENT Preserve the environment – throw away your garbage and recycle when possible. Be kind to animals – they live here, we are only visiting. Please stay out of the kitchen area unless you are assigned to be a helper. Trees are living creatures too – please respect them by not climbing or pulling out their leaves. My signature and applicant’s signature below indicates my/our understanding of the above rules. If rules are violated it may result in myself/child being sent home. Guardian (if under 18) Signature: _____________________________________ Date: _____________________ Applicant Signature: _______________________________________________ Date: _____________________ Camp Rules Pg. 1 PHYSICIAN’S FORM (COMPLETED BY HEMATOLOGIST OR PHYSICIAN) Please note: physician signature is required Camper/Staff Name: _________________________________________ Date of Birth: ______ /______ /______ Date of last exam: ______ /______ /______ Bleeding Disorder: □ Yes Weight: ______ lb. Height: ______ ft. □ Male □ Female □ No Diagnosis Factor Deficiency □ Factor 8 □ vWD2b □ Factor 9 □ vWD2c □ vWD1 □ Carrier 8 Severity □ Mild □ Moderate □ Severe □ vWD2 □ Carrier 9 □ vWD2a □ Other: ____________________ Factor Activity Level _______________ % Inhibitor □ Yes □ No □ Date of last inhibitor test ______ /______ /______ HIV Status □ Positive □ Negative □ On HIV medications Hep C Status □ Positive □ Negative □ On Hep C medications Treatment Factor Name: _______________________ Routine Dose: ____________ Units or ____________ U/kg Does camper/staff self-infuse? □ Yes (independently) □ Yes (needs help) Does camper/staff use EMLA prior to infusing? □ Yes □ No DDAVP/Stimate used? □ Yes □ No Amicar used? □ Yes □ No (but would like to learn) □ No Target joints: □ Yes □ No □ If yes, state which joints: ___________________________ Does camper/staff have a Portocath or Brovic/Hickman? □ Yes □ No Can they go swimming? □ Yes □ No Is camper/staff on prophylaxis? □ Yes □ No If yes, please indicate dosage schedule for camp week: Mon:______ Units Tues:______ Units Wed:______ Units Thur:______ Units Fri:______ Units Sat:______ Units Medications Medication Dose Mon Tue Wed Thur Fri Sat □ as needed □ as needed □ as needed Physician Form Pg. 1 PHYSICIAN’S FORM Continued Camper/Staff Name: ____________________________________________ Physical Exam Area of Interest Abdomen Cardiac Chest Dental Ears, Nose & Throat Extremities Eyes Head Neuro Skin Please check one □ Normal □ Abnormal □ Normal □ Abnormal □ Normal □ Abnormal □ Normal □ Abnormal □ Normal □ Abnormal □ Normal □ Abnormal □ Normal □ Abnormal □ Normal □ Abnormal □ Normal □ Abnormal □ Normal □ Abnormal Explain any abnormalities Allergies Drug allergy: ________________ Type of Reaction: ________________ Treatment: ______________________ Drug allergy: ________________ Type of Reaction: ________________ Treatment: ______________________ Food allergy: ________________ Type of Reaction: ________________ Treatment: ______________________ Food allergy: ________________ Type of Reaction: ________________ Treatment: ______________________ Immunizations Please note: All campers/staff must be fully vaccinated to attend Camp Pascucci. Complete or include a copy of immunization records. Immunization Chicken Pox (Varicella) DTaP Hepatitis A Hepatitis B HPV Influenza MMR Meningococcal Pneumococcal Polio Rotavirus Tdap □ Dose 1 □ Dose 1 □ Dose 1 □ Dose 1 □ Dose 1 □ Dose 1 □ Dose 1 □ Dose 1 □ Dose 1 □ Dose 1 □ Dose 1 □ Dose 1 Schedule □ Dose 2 □ Dose 2 □ Dose 3 □ Dose 4 □ Dose 2 □ Dose 2 □ Dose 3 □ Dose 2 □ Dose 3 □ Dose 2 □ Dose 2 □ Dose 2 □ Dose 2 □ Dose 2 Date Completed □ Dose 3 □ Dose 4 □ Dose 3 □ Dose 4 Physician Form Pg. 2 PHYSICIAN’S FORM Continued Camper/Staff Name: ____________________________________________ Psychosocial Is the camper’s/staff member’s development appropriate for his/her age? □ Yes □ No □ if no, please explain: _________________________________________________________________ Other Recent surgery or illness: □ Yes □ No □ if yes, please explain: _________________________________________________________________ Recent contact with a contagious disease: □ Yes □ No □ if yes, please explain: _________________________________________________________________ Any special instructions? □ Yes □ No □ if yes, please explain: _________________________________________________________________ Physician Contact Information Physician name: ________________________________________ Office/Clinic Name: ___________________ Address: ____________________________________ City: __________________ State: ______ Zip: ________ Phone: _____________________________ After hours/Emergency Phone: ____________________________ My signature below indicates I/my staff has completed the above Physician’s Form for Camp Pascucci. Physician’s Signature (mandatory): _________________________________________ Date: ______________ Please Print Name: ______________________________________________________ Physician Form Pg. 3 APPLICANT INFORMATION (Please keep this information for your use during preparation for camp) Packing Directions MEDICATIONS All medications should be in their original containers, then packed in Ziploc baggies clearly labeled with applicant’s first and last name. Medications must be given to camp nurse at check-in, DO NOT pack medications in your suitcase. All applicants with a bleeding disorder must bring enough of their own factor and infusion supplies to cover treatments for an active week of camp, PLUS 2 DOSES IN CASE OF AN EMERGENCY. Note: Camp supplies of concentrates, if available at all, are extremely limited and will be sued for emergencies only. Not all brands of factor will be available - we do not expect to have any recombinant product on hand at camp. Donated product will likely be plasma-derived (non-recombinant) product. PERSONAL ITEMS Applicants are limited to one (1) duffle bag or suitcase, one (1) pillow and one (1) sleeping bag - each item must be clearly labeled with camper’s first and last name. Applicants should be able to carry all of their own supplies without assistance, please do not pack more than you can carry. COMMUNICATION Mail from home: mail call is an important camp event. If you wish to send mail, please mail your letter/postcard that day camp begins or earlier to ensure its arrival during the week of camp. You can send mail to the following address: YMCA Camp Whittle Attn: Hemophilia – Your Child’s Full Name P.O. Box 70 Fawnskin, CA 92333 Telephone calls: Electronics, especially cell phones are not allowed during the week of camp. Phone calls are only to be made in the event of an emergency. If you should need to reach staff during the week of camp you can call the HASDC office at 619.325.3570 or YMCA Camp Whittle at 909.866.3000. Visitation: Visitations during the week of camp are not allowed. Expectations: all staff members are expected to stay, be present and work the entire week of camp. Leaving camp grounds is prohibited. Breaks are allotted throughout the day by the camp director. Remember, as staff that you are the example and often times mentor to the campers, therefore it is important to always be on your best behavior and to use appropriate language. CAMP PACKING LIST What to Bring to Camp Attention applicant: Please be sure you have everything listed below. Each applicant is limited to one (1) duffle bag or suitcase - don’t pack more than you can carry. Clothing: Shorts (3-4) T-shirts (6) Shoes (two pairs, including good sneakers or hiking boots) Long Pants and/or sweats (2) Underwear (6) Warm sweatshirt or light jacket (1) Socks (7) Pajamas (1) Hat (1) Swimsuit (1) Note: no open toed shoes Toiletries: Toothbrush Toothpaste Brush or Comb Shampoo Soap Chapstick Insect repellent Sunscreen Bedding: Sleeping bag (1) or bedding Pillow (1) Pillow case (1) Twin fitted sheet (1) Other: Towel for swimming & showering- labeled with name Reusable water bottle- labeled with name Optional: Flashlight Flip flops for shower Water shoes for lake activities Pen/paper/stamps Costumes/props for Survivor camp theme Books or magazines Staff Suggestions: “Survivor” decorations for cabin Additional theme related items for cabin/campers Things to Leave at Home Please leave the following items at home as there are prohibited at camp: Cell phones Food/Candy/Snacks DS or other handheld games iPods or other music devices Laptops/tablets Knives/weapons of any kind Matches Money Open toed shoes/sandals (except flip flops for shower) Revealing or offensive clothing (no midriff baring shirts, no shirts with inappropriate language or images) CAMP RULES Please be sure that you/child know and agree to the following camp rules before coming to camp. All campers and staff must abide by camp rules for the duration of the camping week. Campers and staff not following camp rules may be asked to leave camp and transportation must be provided by applicant, parent or guardian. GENERAL DO NOT bring food, candy or drinks with you. If found, items will be confiscated. Electronic equipment of any kind (handheld games, MP3 players, TV’s, Stereos, Cell Phones, etc.) are prohibited at camp. Camp staff will confiscate them. Parents, please keep these items at home! Wear shoes at all times. NO SANDALS OR OPEN TOED SHOES AT CAMP! Throwing rocks (or any object) could injure someone – don’t throw anything at camp. No weapons (knives, guns, sling-shots, other weapons, etc.) are ever allowed at camp at any time. You must be accompanied by a staff person at all times. Follow the buddy system – you should ALWAYS have a buddy with you. You must stay on the camp grounds at all times. Leaving is not permitted. No water balloons as they can cause injuries – water games take place in an organized fashion or at the pool only. No visitors are allowed at any time, without expressing prior permission from our Camp Director. CABIN RULES Stay with your cabin group. Get permission from a counselor before entering another cabin. Respect the space and property of others – stay out of other campers’ belongings. Graffiti (carved or written) is vandalism. We (you) will pay for all damages to camp property. Counselors and campers will jointly make up additional rules for their cabins– follow these! RESPECT Observe the A. D. S. rules at camp – NO Alcohol, NO Drugs, NO Sex at Camp. EVER. This is a non-smoking camp. No smoking is allowed anywhere on camp grounds. Please treat all campers and staff with respect. Teasing, swearing, inappropriate jokes and rude behavior are unacceptable - inappropriate behavior will result in contacting camper’s parent/guardian. ENVIRONMENT Preserve the environment – throw away your garbage and recycle when possible. Be kind to animals – they live here, we are only visiting. Please stay out of the kitchen area unless you are assigned to be a helper. Trees are living creatures too – please respect them by not climbing or pulling out their leaves. POSITION DESCRIPTIONS POSITION TITLE: SUPERVISOR: Senior Camper Counselor in Assigned Cabin GENERAL FUNCTION: To participate under the supervision of the Senior Camper Counselor in planning or implementing activities. Activities are planned for 7-14 year olds in a camping program for children, carriers and siblings affected by bleeding disorders. To actively interact with children while providing a positive young adult role model. To promote and encourage their individual growth. SKILLS: Applicant must be 15 years old (applicant must turn 15 years old by June 2015). Past work with children, including siblings in a recreational or educational setting is desirable. Previous babysitting experience is a plus. An interest in leadership skills and willingness to learn and understand organizational skills and group dynamics. Ability to and interest to help professional staff lead a variety of recreational activities including: sports, games, creative arts and environmental education, and to assist with the implementation of private HASDC camp activities as needed. Ability to perform under stress/pressure while remaining flexible. Ability to recognize the importance of safety at all times. Genuine interest in working with people a must. JOB SEGMENTS: A. PROGRAM DEVELOPMENT As part of a group, work with Senior Counselors and professional staff to carry out recreational activities for 7-14 year olds in a camping program. Stay with your assigned group at all times unless previous arrangements have been made with the Senior Camper Counselor. In leading activities, encourage kids to take responsibility (i.e., clean up after themselves, etc.) Follow all HASDC and program policies, as well as legal guidelines. Attend all staff training events. Report all accidents to the Senior Counselor, who must report them to the Camp Directors. Assist in the maintenance of the camp as needed. This means sweeping and mopping floors, wiping tables/counter tops, putting supplies away, set up and break down of equipment, etc. Report to all camp events and meals on time. Abide by the midnight curfew. Unless otherwise directed. B. PUBLIC RELATIONS Maintain a healthy relationship with all camp personnel. Attempt (with Senior Counselor) to correct any minor (behavior) problems before they become serious problems. Act in a courteous and friendly manner when leading the group in camp. Maintain a non-abrasive relationship with all other cabin groups. C. PERSONAL DEVELOPMENT Be prepared to receive feedback and support from anyone at camp. Maintain a positive and open outlook. Try to work out problems with the rest of the staff. Be sensitive to other staff member needs. Report and discuss all continuous problems and concerns with Senior Counselor and Camp Directors. Be a positive role model for the children. Reward and encourage their good behavior with attention and affection. Develop skills in planning and implementing activities with children. POSITION TITLE: SUPERVISOR: Junior Counselor Counselor in Assigned Cabin GENERAL FUNCTION: To participate under the supervision of the Counselor in planning or implementing activities. Activities are planned for 714 year olds in a camping program for children, carriers and siblings affected by bleeding disorders. To actively interact with children while providing a positive young adult role model. To promote and encourage their individual growth. SKILLS: Applicant must be 16-17 years old (applicant must turn 16 years old by June 2015). Past work with children, including siblings in a recreational or educational setting is desirable. Previous babysitting experience is a plus. An interest in leadership skills and willingness to learn and understand organizational skills and group dynamics. Ability to and interest to help professional staff lead a variety of recreational activities including: sports, games, creative arts and environmental education, and to assist with the implementation of private HASDC camp activities as needed. Ability to perform under stress/pressure while remaining flexible. Ability to recognize the importance of safety at all times. Genuine interest in working with people a must. JOB SEGMENTS: A. PROGRAM DEVELOPMENT As part of a group, work with Counselors and professional staff to carry out recreational activities for 7-14 year olds in a camping program. Stay with your assigned group at all times unless previous arrangements have been made with the Counselor. In leading activities, encourage kids to take responsibility (i.e., clean up after themselves, etc.) Follow all HASDC and program policies, as well as legal guidelines. Attend teen leadership camp and all staff training events. Report all accidents to the Counselor, who must report them to the Camp Directors. Assist in the maintenance of the camp as needed. This means sweeping and mopping floors, wiping tables/counter tops, putting supplies away, set up and break down of equipment, etc. Report to all camp events and meals on time. Abide by the midnight curfew, unless otherwise directed. B. PUBLIC RELATIONS Maintain a healthy relationship with all camp personnel. Attempt (with Counselor) to correct any minor (behavior) problems before they become serious problems. Act in a courteous and friendly manner when leading the group in camp. Maintain a non-abrasive relationship with all other cabin groups. Be a role model for the campers. C. PERSONAL DEVELOPMENT Be prepared to receive feedback and support from anyone at camp. Maintain a positive and open outlook. Try to work out problems with the rest of the staff. Be sensitive to other staff member needs. Report & discuss all continuous problems and concerns with Counselor and Camp Directors. Be a positive role model for the children. Reward and encourage their good behavior with attention and affection. Develop skills in leadership as well as planning and implementing activities with children. POSITION TITLE: SUPERVISOR: Counselor Camp Directors GENERAL FUNCTION: To participate under the supervision of the Camp Directors in planning and implementing activities. Activities are planned for 7-14 year olds in a camping program for children, carriers and siblings affected by bleeding disorders. To actively interact with children while providing a positive adult role model. To promote and encourage their individual growth. SKILLS: Applicant must be at least 18 years old (as of June 2015) and completed at least two years in the Junior Counselor program OR other camp experience. Past work with children in a recreational or educational setting is desirable. An interest in leadership skills and willingness to learn and understand organizational skills and group dynamics. Ability and interest to help professional staff lead a variety of recreational activities including: sports, games, creative arts and environmental education, and to assist with the implementation of private HASDC camp activities as needed. Ability to perform under stress and pressure while remaining flexible. Ability to recognize the paramount importance of safety at all times. A genuine interest in working with people. JOB SEGMENTS: A. PROGRAM DEVELOPMENT As part of a group, help professional staff conduct recreational activities for 7-14 year olds in a camping program. Stay with your assigned group at all times unless previous arrangements have been made with the Camp Directors. In leading activities, encourage children to take responsibility for themselves (i.e., clean up after themselves, etc.) Follow all HASDC and program policies, as well as legal guidelines. Attend all staff training events. Pass background check. Report all accidents to the Camp Directors. Assist in the maintenance of the camp as needed. This means sweeping and mopping floors, wiping tables/counter tops, putting supplies away, set up/break down of equipment, etc. Report to all camp events and meals on time. B. PUBLIC RELATIONS Maintain a healthy relationship with all camp personnel. Attempt (with Directors) to correct any minor behavior problems before they become serious. Act in a courteous and friendly manner when leading the group in camp. Maintain a non-abrasive relationship with all other cabin groups. C. PERSONAL DEVELOPMENT Be prepared to receive feedback and support from anyone at camp. Maintain a positive and open outlook. Try to work out problems with the rest of the staff. Be sensitive to other staff members’ needs. Report and discuss all continuous problems and concerns with Camp Directors. Be a positive role model for the children. Reward and encourage their good behavior with attention and affection. Develop skills in leadership as well as planning and implementing activities with children. POSITION TITLE: SUPERVISOR: General Volunteer Camp Directors GENERAL FUNTCION: General volunteers are always needed to help with a variety of camp related activities. General volunteers are not counselors, junior counselors or medical staff. They stay with other general staff in staff cabins. They are available, on call, and as scheduled to relieve other staff and to back up counselors and junior counselors as well as to provide additional camp assistance and event planning assistance with set-up, clean-up, and event production as needed. POSITION TITLE: SUPERVISOR: Medical Staff Camp Directors GENERAL FUNCTION: Medical Staff Volunteers are certified and registered doctors, physician assistants, nurses, physical therapists, social workers, child life therapists, phlebotomists or other medically oriented team professionals. Medical staff are an important component to the camp program. Medical staff report to the Camp Directors. Medical staff are requested to arrive at camp on Sunday June 14th to prepare the med shack for camper arrivals, but may receive an exemption if they have extensive camp experience or have worked extensively with the hemophilia population in the past. POSITION TITLE: SUPERVISOR: Co-Director HASDC Executive Director GENERAL FUNCTION: Please contact the HASDC office for further details.
© Copyright 2024