form 1

Contact Information

First Name*

Last Name*

Date of Birth

Cell Number

Email*

T-shirt Size (S – XXXL)

Contact Information

Street Address*

City*

State*

Zip Code

Emergency Contact Information

First Name

Last Name

Relationship

Cell Number

Email

First Name

Last Name

Relationship

Cell Number

Email

First Name

Last Name

Relationship

Cell Number

Email

Hope Camp Champ Volunteer Descriptions

Camp BUDDY: Buddies work directly with their assigned camper maintaining close proximity. The Buddy is responsible for attending to the camper’s needs, reinforcing TBRI® principles consistently with the camper, and modeling those principles for the camper’s parents. The Buddy must be able to get down on the floor, run, and participate in other physically strenuous activities with their camper. Buddies must also participate in both camp days. **Must attend the full day training 8/14/21 9am-5pm and ½ day refresh training on 8/28/21 12-5pm
Camp SPECIALIST: Specialists facilitate daily camp activities (Art, Speech, Language, Sensory Integration, Life Skills, Crash & Bump, Outside water play, Memory Books, and Nurture Groups). Specialists schedules can be somewhat flexible. Specialists who are willing and able may also serve as Buddy Floaters to provide breaks for Camp Buddies. **Must attend the full day training 8/14/21 9am-5pm and ½ day refresh training on 8/28/21 12-5pm.
Camp SUPPORT: Supporters provide an administrative role at camp and are essential to the overall success of the camp. Camp supporters may help by providing financial support for specific needs, or hands-on support like serving food, setup/clean-up activities, runners for specialists and Buddies, medical support, photo/video skills. **Must attend ½ day training on 8/28/21 9am-1pm.

Do you have any medical or dietary concerns of which we should be aware?

Which Hope Camp Champ Volunteer Role do you prefer?

Buddy
Specialist
Support

Briefly describe what you hope to gain from volunteering in this camp?

What is your previous experience working with children?

What are your special areas of interest or skills that might be interesting to a child or helpful to the camp project? Examples might include: sports, arts and crafts, computers, board games, swimming, or teaching a skill.

What are your future plans? Career Goals? How might this experience contribute to those goals?

Please give 5 adjectives that most accurately describe you:

1

2

3

4

5

Adjectives 1

Adjectives 2

Adjectives 3

Adjectives 4

Adjectives 5

What would you consider to be your strongest attributes?

Are you willing to be photographed and/or videotaped?

References

First Name

Last Name

Title/Relationship

Cell number

Email

Ref.1 First Name

Ref.1 Last Name

Ref.1 Title/Relationship

Ref.1 Cell number

Ref.1 Email

Ref.2 First Name

Ref.2 Last Name

Ref.2 Title/Relationship

Ref.2 Cell number

Ref.2 Email

Ref.3 First Name

Ref.3 Last Name

Ref.3 Title/Relationship

Ref.3 Cell number

Ref.3 Email

Authorization for Reference Checks

I, hereby authorize Counseling Connections for Change, Inc. or any designated officer, employee, agent, or representative to confer with the references provided. I understand that the Company may ask my references questions about my educational background, work experience, achievements, wage history, performance, attendance, and reason for separation from former employment. I expressly authorize my references to answer such questions. I understand that any information provided by my references will be used solely for the purpose of determining my acceptability for employment/volunteer with the Company. I release all of the above-named references from any claim of liability or damages, including, but not limited to, claims for defamation, interference with contract, and negligence—which may arise or result from any truthful reference information provided by a reference pursuant to this authorization.

Auth. Signature of Applicant

Auth. Date

Auth. Applicant Name – Printed

Signature of Applicant

Date

Applicant Name – Printed

Confidentiality Agreement

I, understand that confidentiality is important to building trust while working with children and families. As a volunteer, I agree to keep confidential the names and any identifying information pertaining to clients of Counseling Connections for Change, Inc., which may include, but is not limited to the details of my work with the families, posting any information on social media that has photos or other identifying information about the campers, their families, or other volunteers.

Confi. Signature of Applicant

Confi. Date

Confi. Applicant Name – Printed

Signature of Applicant

Date

Applicant Name – Printed

Authorization for Background Check

I, , hereby authorize Counseling Connections for Change, Inc. to investigate my background and qualifications for purposes of evaluating whether I am qualified for the position for which I am applying. I understand that Counseling Connections for Change, Inc. will utilize an outside firm or firms to assist in checking such information, and I specifically authorize such an investigation by information services and outside entities of the company's choice. I also understand that I may withhold my permission and that i

Auth2. Signature of Applicant

Auth2. Date

Auth2. Applicant Name – Printed

Signature of Applicant

Date

Applicant Name – Printed

Demographic Information for Criminal Background Checks

Full legal name:

DOB:

SS#:

List any alias(s) you may have had:

List your maiden name (if applicable):

Address for past 5 years including city and state:

List all states you have ever lived in:

Have you ever lived out of the country? If so, when and where:

* * * * *

By signing below, I agree that I have responded truthfully to the best of my knowledge. I also acknowledge that by signing this volunteer application, I am committing to the required interview expectations, training dates and camp session dates listed above. I understand that if accepted as a volunteer for this camp, my position will be critical. I agree that if there is an emergency situation that cannot be avoided that takes me away from my commitment to serve, I will immediately inform the Camp Coordinators of the change.

Ack. Signature of Applicant

Ack. Date

Ack. Applicant Name – Printed

Signature of Applicant

Date

Applicant Name – Printed

Camp Champ Application