| To print this form, use your browser print function. [Move your mouse to file in the upper left, then choose print] |
| *Last name:___________________________________*First name________________ *Day Phone____________________________ Evening phone _____________________ Other phones ___________________________________________________________ *Address:_________________________________________________________ *City: _________________________________State & Zip:___________________ *e-mail (helps us with back and forth information if needed)_____________________________ *Medical & Dental Insurance Co. & Policy #: ____________________________________ _________________________________________________________________________ *List 2 adult friends to contact in case of an emergency 1. ___________________________________ Phone: ____________________________ 2. ___________________________________ Phone: ____________________________ *Applicant has or is subject to (if yes, please circle and explain): asthma, diabetes, fainting, heart trouble, convulsions, sleepwalking, etc. Explain: ____________________________________________________________________________ *Allergy or reaction to any medication, foods, etc. Please list and explain: ____________________________________________________________________________ *Describe any condition now requiring regular medication or a restriction of activities for med. reasons: ___________________________________________________________________________ *PLEASE READ AND SIGN: "In case of an emergency, this will authorize the camp staff, a physician, or hospital to provide medical treatment as deemed necessary. I will not hold the Director or any staff members liable in case of an emergency or accident. I promise to pay all medical expenses if I become sick or injured. I affirm that my tetanus inoculation is current" Signed: _________________________________________________date ______________ __ My camp name will be ______________________________ (Subject to approval) Please copy this form, fill it out and e-mail it directly to me, Darren Nettrouer (teaching / schedule coordinator), dbnett10@gmail.com. If you have further questions about volunteering please e-mail and I will contact you by e-mail or phone if you wish. Outdoor School Science Camp Volunteer Service Application Personal Information Legal Name:_________________________________________________________________________________________ (Last) (First) (Middle) Address: ____________________________________________________________________________________________ City State Zip Length of time at above address:_________________________________________________________________________ Home Phone: ______________________ Work Phone: _____________________ E-Mail:__________________________ Occupation: _______________________________________ Employer: ________________________________________ Education, Training, Experience If a student, school attending: ___________________________________________________________________________ Education and/or special training: ________________________________________________________________________ Languages spoken (other than English): ___________________________________________________________________ Special skills, interests and/or hobbies: ____________________________________________________________________ Have you had CPR training? (when): _________________ Have you had First Aid training? (when): __________________ Background in this and Other Youth Programs Have you been a camp counselor before? Yes: ___ No: ___ If yes, where and how long? ___________________________________________________________________________________________________ Experience in other youth programs: ______________________________________________________________________ Memberships in other organizations: ______________________________________________________________________ References (At least one should be your pastor or minister, etc. - not family members/relatives) - Please include complete mailing address. 1. Pastor: ___________________________________________Home Phone: ______________Work: ___________ Address:___________________________________________________________________ E-mail____________________ 2. Name: ___________________________________________ Home Phone: ______________ Work: __________ Address: ___________________________________________________________________ E-mail____________________ 3. Name: ___________________________________________ Home Phone: ______________ Work : __________ Address: ___________________________________________________________________ E-mail____________________ Please note: A criminal record will not necessarily disqualify an applicant. A criminal record will be considered as it relates to specifics of the position.A conviction includes a plea of no contest, plea of guilty or any court determination of guilt. Have you ever been convicted of a crime involving offenses against children? Yes: _____ No: _____ Have you ever been convicted of a crime involving physical harm to another person? Yes: _____ No: _____ Have you ever been convicted of a crime involving a firearm? Yes: _____ No: _____ Within the past 10 years, have you been convicted of a crime involving theft or dishonesty? Yes: _____ No: _____ Within the past 10 years, have you been convicted of a crime involving possession of a controlled substance? Yes: _____ No: _____ If yes, please explain:__________________________________________________________________________________
Adult Volunteer Expectations We strive to provide quality leadership for youth participating in this program. The opportunity to work with youth is a privileged position of trust that should be held only by those who are willing to demonstrate behaviors that fulfill this trust. The following behavior expectations are provided for volunteers working in the Outdoor School / Science Camp.
Why are you interested in an Outdoor School counselor or teacher position? ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________ Please read the following before signing:
____________________________________________________________________________________ Signature of Applicant Date Oregon Drivers License # For office use only Date Received: ________________ Application Reviewed By: __________________ Approved:_____________________ Status of References:___________________________________________________________________________________ Leader Education (orientation/training): ___________________________________________________________________ Comments: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ |