Welcome to Camp Heart Connection's Volunteer Staff Application! Please note that all applications must be submitted no later than March 6, 2013.

Volunteers must be 16 years or older to apply.

Oncology Camp dates for volunteers are June 8 - 15 and Sibling Camp dates for volunteers are August 10-17.

If you are selected as a part of Camp Heart Connection's Staff, you must commit to the entire week.

NEW STAFF: You must submit two personal reference forms to complete your application.  Please visit www.childrenscancerconnection.org/volunteer for more information.

 Please fill out the form below to apply:

First Name	*
Middle Name	*
Last Name	*
Social Security Number	* Please use hyphens. Example: 123-45-6789.
Birth Month	*	- - 01 02 03 04 05 06 07 08 09 10 11 12
Birth Day	*	- - Choose One - - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Birth Year	*	1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Age at Camp	*
Sex	*	Male Female
T-shirt Size:	*	Small Medium Large X-Large 2X-large
Name as you would like it to appear on name tag:	*
CONTACT INFORMATION
Children's Cancer Connection will use this address and e-mail address to send information frequently, please put an address that you will use throughout the summer.
Cell Phone Number (do not include hyphens)	* DO NOT use hyphens between numbers
Address	*
Apartment or Suite Number
City	*
State / Province	*	- - Choose One - - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip / Postal	*
Email Address	*
I am:	*	A Returning Staff Applicant A New Staff Applicant
- - NEW STAFF ONLY - -
--All NEW applicants must have 2 personal reference forms completed by 2 individuals NOT related to you.
--References must be received by Children's Cancer Connection by March 11, 2013, for your application to be considered.
--Please visit www.childrenscancerconnection.org/volunteer to access the online reference form or to download a PDF copy.
All NEW applicants are required to attend an interview session. Please indicate which session you'll attend below.
New Staff Interview	*	--Select Option Below-- Iowa City on Tuesday, March 12 - 5:30-6:30 PM Iowa City on Tuesday, March 12 - 6:45-7:45 PM Cedar Falls on Wednesday, March 13 - 6:00-8:00 PM Des Moines on Thursday, March 14 - 6:00-7:00 PM Des Moines on Thursday, March 14 - 7:00-8:00 PM I am unable to attend a scheduled date and I will contact Elly Shaw to make other arrangements. I am a returning staff. (Returning staff does not have to interview.)
TO BE COMPLETED BY ALL APPLICANTS
Person to be contacted in case of an emergency:
First Name	*
Last Name	*
Relationship	*
Phone One (do not include hyphens)	*
Phone Two (do not include hyphens)	*
Street Address	*
City	*
State	*	- - Choose One - - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Medical History:
Operations or serious injuries (dates):
Chronic or reoccuring illness:
All positions at camp are physically demanding. Are there any reasons you may have difficulty in performing any of the essential functions of the job for which you applied?	*	Yes No
If yes, please explain:
Name of Family Physician:
Physician's Phone Number (do not include hyphens)
Insurance Information:
Do you carry medical/hospital insurance?	*	Yes No
If so, indicate carrier:
Policy or Group Number:
Name of Person with Insurance (first and last):
Carrier Street Address:
Carrier City:
Carrier State:		- - Choose One - - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Carrier Zip Code:
Please submit a copy of your insurance card one of four ways:
1.) Upload below (preferred method)
Please upload a copy of your insurance card.
2.) Email to Elly@ChildrensCancerConnection.org
3.) Fax to 515-243-5232
4.) Mail to Children's Cancer Connection, 1221 Center Street, Suite 12, Des Moines, IA 50309
Immunization History:
Date (month and year) of last tetanus booster:	*
Date (month and year) of last MMR:
Please list other vaccines and dates:
Health History: Check if YES		Frequent Ear Infections Heart Defect/Disease Convulsions/Seizures Diabetes Bleeding/Clotting Disorders High Blood Pressure Mononucleosis Asthma
Diseases: Check if YES		Mumps Chicken Pox
Date(s) of Disease(s):
Allergies: Check if YES		None Hay Fever Penicillin
Other Drug Allergies:
Other Allergies:
Education:
High School
Last Grade Completed		10 Grade 11 Grade 12 Grade
College/University
Major(s)
Level of Education Completed		Some college, no degree Some college, anticipated degree Bachelor's Degree Masters Degree Doctorate Degree
Employment: Please list current first.
Employer and Supervisor:
Phone Number (do not include hyphens)
Dates:
Reason for Leaving:
Employer and Supervisor:
Phone Number
Dates:
Reason for Leaving:
Camp Experiences other than Camp Heart Connection:
Camp Name:
Dates:
Camp Address:
Camper or Staff?		Camper Staff Both
Past Family Illness:
Has any member of your family or a close friend ever had cancer or been seriously ill?		Yes No
If yes, please explain:
Criminal History: A yes answer does not disqualify you from applying. Each applicant will be considered on a case-by-case basis.
Have you ever been convicted of a crime?	*	Yes No
If yes, please state what crime and when:
Camp Session Preference
Which camp session would you most like to participate in?	*	--Choose One-- Oncology Camp: June 8 - 15 Sibling Camp: August 10 - 17 No Preference - I'd be willing to work at either camp.
If you are not selected for your first choice, are you able to participate in the other camp?	*	Yes No
If you were given the opportunity to participate in both camps, would like like to do so?	*	Yes No
NEW STAFF ONLY
Are you a past Heart Connection camper?		No Yes, I was a Oncology Camper Yes, I was a Sibling Camper
How many years were you a camper?
If you are not a former camper, how did you find out about Camp Heart Connection?
RETURNING STAFF ONLY
Number of weeks as a STAFF member at ONCOLOGY CAMP (not including 2013):
Number of weeks as a STAFF member at SIBLING CAMP (not including 2013):
Number of weeks as a HEART CONNECTION CAMPER:
Are you willing to help out during staff training?		Yes No
Past Experience:
Please describe all of your past experiences working with individuals with special needs (including cancer), diverse populations, or children in general that has not previously been mentioned elsewhere on this application. Include the length of time and type of role for each example.
	*
The mission of Camp Heart Connection is to create a safe and nurturing environment where children touched by childhood cancer are empowered to become more confident, independent, and build positive relationships. How will you help each camper increase confidence, independence, and create positive relationships while at camp?
	*
Every year Camp Heart Connection receives hundreds of applications and we are not always able to offer positions to everyone.
Please keep in mind that the more flexible you are, the more likely you are to be selected.
Position Ranking: Please rank the positions below from 1 to 4, with 1 being your top preference.
**If you are unwilling to accept a position, please do not rank it.
Arts and Crafts (must be 17) Responsible for facilitating and leading Arts & Crafts activities at camp. Applicants should be flexible, creative and comfortable working with children of all ages. Major pluses: Arts & Crafts leaders get to touch the lives of each and every child that comes to camp and they have some freedom to choose the cabins that they spend time with. Arts & Crafts leaders sleep separately from campers, so there are no late night “potty” trips!
Arts & Crafts Ranking:	*	--Choose One-- 1 (Most Prefer) 2 3 4 (Least Prefer) No Preference
Dishwasher (must be 16) Responsible for light kitchen work as well as washing all of the dishes. Applicants should have a positive attitude, be flexible, hardworking and excited about jumping into camp activities when not in the kitchen. Major pluses: unlimited access to good, hot food! This is one of the most important positions at camp. Dishwashers also have the ability to jump into camp activities when they have breaks, so they can pick and choose their favorite things to do at camp!
Dishwasher Ranking:	*	--Choose One-- 1 (Most Prefer) 2 3 4 (Least Prefer) No Preference
Counselor (must be 18) Responsible for the direct supervision and care for a cabin of children. Applicants should be responsible, compassionate, flexible and comfortable living without a lot of privacy for a week. Major pluses: getting to know a small group of kids really well.
Counselor Ranking:	*	--Choose One-- 1 (Most Prefer) 2 3 4 (Least Prefer) No Preference
Program Leader (must be 17) Responsible for leading songs, planning and setting up all camp programs and filling in wherever needed from helping with challenging campers to lifting boxes. Applicants should be upbeat and comfortable leading games and songs in front of a large group, have the ability to work with limited supervision and be comfortable doing some hard work. Major pluses: getting to be on-stage constantly, getting to work with all age groups and getting to use your talents to help with programming.
Program Leader Ranking:	*	--Choose One-- 1 (Most Prefer) 2 3 4 (Least Prefer) No Preference
Please keep in mind that these are just short descriptions of each job. ALL camp staff must be responsible, flexible and great role models for children to look up to!
Age Group Ranking:
Please rank these groups from 1 to 3, with 1 being the age you most prefer to work with and 3 being the age you least prefer to work with. If you have past experience working with that age group, please describe in the space provided. Your preference will be taken into consideration. If you are accepted we will place you where you are most needed. Please do not request specific cabins, campers or friends that you would like to work with.
5-8 Year Olds	*	--Choose One-- 1 (Most prefer) 2 3 (Least prefer) No preference
Past Experience:
9-12 Year Olds	*	--Choose One-- 1 (Most prefer) 2 3 (Least prefer) No preference
Past Experience:
Teens	*	--Choose One-- 1 (Most prefer) 2 3 (Least prefer) No preference
Past Experience:
Consent Information: The following consents are for (Applicant's Legal Name)...
First Name	*
Middle Name (Not Abbreviated)	*
Last Name	*
Permanent Address (Number, Street, City, State, Zip):	*
To be completed by all applicants. Form must be signed by parent/guardian if under 18.
Authorization for Treatment:
I, for and on behalf of myself or the applicant named above, hereby give permission to the medical staff of Children's Cancer Connection, selected by the camp director, to order X-rays, routine tests and treatments; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for me/or my child. In the event of an emergency, I hereby give permission for myself/my child to be treated by the physician selected by the camp director or camp medical personnel to secure and administer treatment, including hospitalization, for the person named above. I understand that I am responsible for any and all medical treatment costs that may be incurred by myself/my child while volunteering for Children's Cancer Connection. This completed form may be photocopied for trips outside of camp.
Applicant's Acceptance:	*	Yes, I agree to the terms of the Authorization for Treatment statement above.
Date:	*
Parent/Guardian Acceptance (if under 18):		Yes, I agree to the terms of the Authorization for Treatment statement above.
Date:
Camp Attendance Consent Form & Media Consent:
In consideration of Children's Cancer Connection granting permission to the applicant named above to participate as a volunteer camp staff member, the undersigned, for themselves, their legal representatives, successors, and assignees, hereby waive and release any and all rights, claims, demands, and actions whatsoever for damages or loss which the undersigned may have against Children's Cancer Connection. I also grant permission for myself/my child named above to be transported by a licensed company, to any and all camp activities held off camp premises. I do hereby authorize the interviewing, taking of pictures, motion pictures/video, and/or television pictures of myself/my child, while participating at Children's Cancer Connection's camp, and consent to the use of any or all such pictures in publication media, as well as for use on Children's Cancer Connection's web site, except as noted. (This includes pre-camp press releases announcing participation in the summer camps, as well as my own/my child’s name, address, phone number, and e-mail printed in the annual camp yearbook for distribution amongst camp participants and volunteers.)
Explanation:
Applicant's Acceptance:	*	Yes, I agree to the terms of the Camp Attendance and Media Consent statement above.
Date:	*
Parent/Guardian Acceptance (if under 18):		Yes, I agree to the terms of the Camp Attendance and Media Consent statement above.
Date:
Final Consent:
I authorize investigation of all statements herein and release the camp and all others from liability in connection with the same. I also understand that untrue, misleading, or omitted information herein may result in dismissal, regardless of the time of discovery by Children's Cancer Connection.
Applicant's Acceptance:	*	Yes, I agree to the terms of the Final Consent statement above.
Date:	*
Parent/Guardian Acceptance (if under 18):		Yes, I agree to the terms of the Final Consent statement above.
Date:
Security Code	*