Camp Champ Application - Counseling Connections For Change

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?
Do you have any medical or dietary concerns of which we should be aware?
Which Hope Camp Champ Volunteer Role do you prefer?
Which Hope Camp Champ Volunteer Role do you prefer?
- Buddy
- Specialist
- Support
Briefly describe what you hope to gain from volunteering in this camp?
Briefly describe what you hope to gain from volunteering in this camp?
What is your previous experience working with children?
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 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?
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?
What would you consider to be your strongest attributes?
Are you willing to be photographed and/or videotaped?
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:
Address for past 5 years including city and state:
List all states you have ever lived in:
List all states you have ever lived in:
Have you ever lived out of the country? If so, when and where:
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

By hitting submit, you understand that Counseling Connections for Change, Inc. has your permission to use yours or your child’s photograph publicly to promote the Hope Camp in the future. You understand that images may be used in print publications, online publications, presentations, websites, and social media. You also understand that no royalty fee or other compensation shall become payable to you by reason of such use.