Camp Discovery 2013 Volunteer Staff Application

Submission Deadline: April 8, 2013

Personal information

First Name:
Middle Name:
Last Name:
Other names by which known (i.e. maiden name):
Gender:
Date of Birth:	(mm/dd/yyyy)
Home Address:
City:
State:
Zip:
Primary Phone:
Email:
How did you find out about Camp Discovery?
Do you have a skin condition?
Diagnosis:

Work / School

Current Employer or School:
Address:
City:
State:
Zip:
Phone:
Type of Work:

Camp you are applying for:

Camp Little Pine, ages 10-14, Crosslake, MN – June 23-28 (staff would arrive on June 22)
Camp Reflection, ages, 8-16, Carnation, WA – June 24-28 (staff would arrive on June 23)
Camp Big Trout, ages 14-16, Crosslake, MN – July 7-12 (staff would arrive on July 6)
Camp Dermadillo, ages 9-15, Burton, TX – August 11-16 (staff would arrive on August 10)
Camp Horizon, ages 8-13, Millville, PA – August 10-17
Camp Liberty, ages 8-16, Hebron, CT – August 11-17

Please note that you may be required to arrive one day early for orientation.

Position you are volunteering for:

Counselor/medical student
PA
MA
RN
LPN
Nurse Practitioner
Physician
Resident

Tell us about your medical training if applicable:

Additional Information

Please describe your abilities and motivations that you believe will make you a valued member of the volunteer staff at Camp Discovery.

Do you have any experience in supervising and working with children? Explain.

Do you have any particular skills, training or expertise that could be incorporated into a camp activity?

What expectations do you have for your time at camp and what would you like to get out of the week?

References

Please list three adult references that are not direct family members or friends. Appropriate references are teachers, supervisors, employers, or other authority figures that can attest to your degree of maturity and responsibility and your ability to work as a team player.

Reference 1
Name:
Relationship:
Phone Number:
Email:

Reference 2
Name:
Relationship:
Phone Number:
Email:

Reference 3
Name:
Relationship:
Phone Number:
Email:

Letter of Reference

Please attach one letter of reference below, or send the letter to Janine Mueller:

Address:
Janine Mueller
American Academy of Dermatology
930 E Woodfield Rd
Schaumburg, IL 60173

Fax:
(847) 330-8907
Email:
jmueller@aad.org

Attach letter:

Disclosure

Do you use illegal drugs? No
Yes

Have you ever been convicted of a criminal offense? No
Yes

Have you ever been charged with child abuse or neglect? No
Yes

Has your driver's license ever been suspended or revoked? No
Yes

Is there any other circumstance involving you or your background that would call into question your being entrusted with the supervision, guidance, and care of young people? No
Yes

Conditions

In submitting this application, I affirm that the information that I have given is true and correct. I realize that if I am selected as a staff member at Camp Discovery I must abide by the conditions below:

I must attend the orientation session.
I authorize the American Academy of Dermatology/Camp Discovery to conduct background checks and reference checks.
I will not be allowed to smoke on camp grounds.
The use of alcohol or any illegal drugs will be strictly forbidden.
I will abide by all American Academy of Dermatology policies or risk being sent home at my own expense.

A representative of Camp Discovery will contact you for additional information.