2019 Camp Kindle Returning Staff Form
This form must be completed in its entirety by the staff member. This form will take approximately 30-60 minutes to complete. You cannot return to this form later, so you must complete it all now. Please SCROLL DOWN to see what all information you will need and acquire that information PRIOR to filling out this form. No information will be saved until you submit at the very end.

Be sure to bring your insurance card and a copy of your immunization record. You may email/fax these to camp as well.

Questions? Email or call Minnow or Cabbage

Email: glorimar@projectkindle.org - charisa.projectkindle@gmail.com
Phone: 626.736.8294

Thanks!
Staff Member's Full Name *
Your answer
CURRENT Email Address (that you check at least weekly) *
Your answer
Training and Session Dates
STAFF TRAINING: ALL STAFF ONLINE TRAINING via ZOOM
June TBD

CK MIDWEST (NEBRASKA)
Sat July 27th Staff report to Camp (Time TBD)
Sun July 28th: Staff Training begins at 8am
Camp Kindle Midwest Mon-­Sat July 29­-Aug 3
What were your strengths in your previous position(s)? *
Your answer
Where could you improve within your previous position(s)? *
Your answer
Where do you think you would fit best as a staff member this summer? Why? *
Your answer
Date of Birth *
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Permanent address (include city, state, and zip) *
Your answer
Preferred Phone # (with area code) *
Your answer
Emergency Contact #1: Full Name *
Your answer
Emergency Contact #1: Relationship to Staff Member *
Your answer
Emergency Contact #1: Main Phone including Area Code *
Your answer
Volunteer Release Form
I, a volunteer Camp Kindle staff member, understand and agree to abide by all program policies and procedures, including the Code of Ethics and Code of Conduct.

-I understand that any violation of policies and procedures could result in my termination as a camp volunteer and/or legal action against me.
-I understand that participation as a volunteer for Camp Kindle is voluntary.
-I understand that occasionally accidents occur during camp activities and that participants may sustain serious personal injury and property damages as a consequence thereof. Knowing the risks of camp activities, nevertheless, I agree to assume those risks and by digitally signing this liability release, I intend to legally bind myself, my minor children, my heirs, executors, and administrators. I hereby release and forever discharge Camp Kindle and the location of camp, and any of their officers, directors, employees, and agents from all claims, causes of action or damages arising out of any injury, illness, or loss of any kind, known or unknown, including but not limited to injuries to property or person, to me during or related to my attendance at Camp Kindle.
Authorization to be Photographed
I give Camp Kindle and the campsite the right to interview and/or to take photographs, audio or audio-visual recordings of me to be used in promotional, educational or fundraising materials including, but not limited to videotapes, pamphlets, and brochures. I understand my name may be used in connection with these materials. By signing this media release, I intend to legally bind myself, my minor children, my heirs, executors, and administrators. Camp Kindle shall have the right to use photographs or other images of me in promotion, educational or fundraising materials. I acknowledge that Camp Kindle shall have all rights of copyright in and to such photographs and videotapes and may use such copyright fully. I also hereby release Camp Kindle and its officers, agents, and employees from all liability connected with the taking and use of these materials as is authorized by Camp Kindle. In addition, I waive all rights, interest, or claims for payment in connection with any exhibition or release of these materials. This consent is voluntary, and I give it in the interest of public information, education, the furtherance of the goals of these institutions, or other lawful purposes. I acknowledge that I have legal authority to sign this form on behalf of the name mentioned above. This release is valid for ONE FULL YEAR from the date listed below.
Choose one in regards to the above photography release: *
Confidentiality Policy
Camp Kindle staff will protect client confidentiality by obtaining specific written permission from the client to release any information (including client status) to any person or agency for any reason. ANY ASSOCIATION OF THE CLIENT'S NAME WITH YOUR NAME AND/OR AGENCY AFFILIATION THAT IS DISCLOSED TO ANY THIRD PARTY COULD CONSTITUTE A RELEASE OF CONFIDENTIAL INFORMATION (HIV DIAGNOSIS). This includes, but is not limited to, written and verbal communication and photographic images.

All case information must be safeguarded against any possibility of disclosure to unauthorized persons, even anonymous descriptions of situation or circumstances.

1) No information regarding any case should be talked about in public, regardless of how "harmless" or generic it might be. this applies to conversations in person or by public phone, with other staff members or volunteers, or service providers.

2) Client names or other identifying materials must be discussed in private offices only. Care should be taken to avoid talking about a client's case.

3) If you encounter a client in public, exercise some discretion by "hanging back" a bit to allow the client to speak to you or choose not to. The client may find it very difficult to explain who you are to others in his or her company.
Participation Consent
I understand an certify that my participation in Camp Kindle is completely voluntary. I have familiarized myself with the program and activities at Camp Kindle in which I will be participating. I recognize that certain hazards and dangers are inherent in these activities, which may include, but are not limited to, the activities of wall climb, swimming, archery, and canoeing. I acknowledge that although Camp Kindle has taken safety measures to minimize the risk of injury to camp participants, Camp Kindle cannot insure or guarantee that the participants, equipment, premises, or activities will be free of hazards, accidents, or injuries. I recognize the importance of knowing and abiding by the rules, regulations, and procedures for Camp Kindle. Further, I have received approval from a doctor authorizing me to participate in the Camp Kindle activities. I also agree to inform Camp Kindle staff of any activities in which I may not participate.
Fundraising Commitment
We encourage every staff member to raise at least $400.00 to help cover the cost of their presence at camp. This will allow us to use our funds to help bring more children to camp this summer. This can be done through a letter writing campaign, email campaign, donating additional time or resources or by participating in or conducting a fundraiser. We will give you necessary resources to help you reach your goal. Though not mandatory, setting this fundraising goal goes a long way towards helping the children of Camp Kindle. I understand and am willing to help raise funds for Camp Kindle this year.
I will help reach the fundraising goal set out for staff
Drug-Free Workplace Policity
Camp Kindle recognizes that substance and/or alcohol abuse is a serious and complex condition that negatively affects the productive work, personal, and family lives of volunteers. Camp Kindle is committed to providing a safe work environment for all volunteers, including a workplace free from the effects of alcohol and illegal drugs.

Each volunteers is hereby informed that it is illegal to manufacture, distribute, dispense, possess, or use alcohol or illegal drugs in the workplace. The possession of physician-prescribed drugs, verifiable by current prescription, is an exception to this policy. However, it is a violation of this policy to be "under the influence" of such physical-prescribed drugs. If there is reason to suspect that a staff member is under the influence of an illegal drug or alcohol, the staff member will be suspended until the results of a drug and alcohol test are made available to Camp Kindle.

A volunteer who violates this Drug-Free Workplace Policy will be subject to disciplinary action including suspension and dismissal, and may be required to satisfactorily complete an approved rehabilitation program.
Acknowledgment
IF THERE IS ANY PORTION OF THIS DOCUMENT THAT NEEDS CLARIFICATION I KNOW THAT I CAN CONTACT Minnow!

I HAVE READ AN UNDERSTAND THESE RELEASES AND POLICIES AND AGREE TO ABIDE BY THE CAMP KINDLE POLICIES.
Type Name:
Your answer
Camp Kindle Code of Ethics
Read the following and then digitally sign and date below.

• Staff understand and embrace the mission of Camp Kindle and willingly and knowingly accept the concept that the focus and goals of the camp are directed to the campers

• Staff will never leave a camper unsupervised

• Staff will never be alone with a camper violating Three’s Company

• Staff will not abuse campers, including:

• Physical abuse- strike, spank, shake, slap

• Verbal abuse- humiliates, degrade and threaten

• Mental abuse- hazing, negative manipulation

• Sexual abuse- including inappropriate touching

• Staff will use positive guidance techniques including redirection, anticipation of and elimination of potential problems, positive reinforcement, support and encouragement rather than competition, comparison, criticism or humiliation discipline techniques

• Staff must treat with confidence and respect personal information they learn from campers, subject to the policies on reporting abuse and neglect

• Staff will treat campers of all ethnic, religious and cultural backgrounds with respect and

• Staff will portray a positive role model for campers, including but not limited to, maintaining an attitude of respect, loyalty, patience, honesty, courtesy, tact and maturity

• Staff will not use profanity or discuss adult subject matter in the presence of campers

• Staff will adhere to the dress code for camp

• Staff will not use, possess or be under the influence of alcohol or illegal drugs during camp

• Staff is prohibited from having firearms or other weapons while at camp

• Staff must be free of health or psychological conditions that might affect campers’ health

• Staff will comply with the outlined activities and expectations of their defined roles at camp and all required activities prior to camp, which support their roles

• Staff are prepared and willing to assist and support campers to meet personal daily needs

• Staff will accommodate and be sensitive to the developmental differences and abilities of

• Staff who does not have a pre-existing relationship with a camper will not fraternize with campers outside of Camp Kindle supervised activities or the camp setting. Any exception to this policy requires approval from the President and/or the Camp Director

• Staff will not offer money to campers or their families

• Staff are required by Nebraska, California, and Illinois State law to report any suspected abuse or neglect of a child to the Psychosocial Team and/or the Camp Director so that it may be

• Staff will not make personal disclosures to campers with or without an attempt to influence individual beliefs, values or lifestyles

• Staff will adhere to the outlined policies, procedures and standards of Camp Kindle

• Staff must agree to provide all criminal and other background check information requested of them and must meet qualification standards established by Camp Kindle
Staff Member Health History
The various sections below include allergies, nutrition, chronic concerns, immunization history, medication, general physical history, mental & emotional health information, paying for health care, and authorization for health care. You will be required to digitally sign and date at the very end.
Allergies
Choose all that apply. In the next question, you will be asked to elaborate if needed. *
Required
If you checked that you have food, medication, or substance allergies, please elaborate below, INCLUDING whether or not the allergy causes anaphylaxis AND the reaction you have AND how the reaction is managed. If you do not have any allergies, type NA. *
Your answer
Nutrition
Our expectation is that staff set an example for campers by eating the provided menu. We can work effectively with some medically prescribed diets, but cannot cater to individual food preferences. There are times when you might need to simply not eat a served item.
I eat a regular, varied diet and am prepared to eat a variety of foods while at camp. *
I am a vegetarian of this type (choose one): *
I am lactose-intolerant. Be prepared to manage your intolerance using products such as Lactaid or food avoidance. *
I avoid certain foods because of religious beliefs. List foods below or write NA if this doesn't apply. Camp kitchens are not kosher. *
Your answer
I respond with an anaphylactic reaction when I eat the following food(s). If this doesn't apply, write NA. *
Your answer
Chronic Concerns
If you have asthma or diabetes, you may be asked to fill out additional forms before or at camp.
Check all that pertain to you. In the next question, please provide information about supportive health care. *
Required
For EACH checked item above, list the # and provide information about supportive healthcare needed. If you have no chronic conditions, please type NA. *
Your answer
Immunization History
Provide the month and year for immunizations. Asterisked (*) immunizations must be current. This website may be beneficial to help you translate immunization information - OPEN IN A NEW WINDOW - http://www.vaccines.gov/diseases/index.html
Tetanus Booster* (current within 10 years) *
Your answer
Polio* *
Your answer
Varicella* (Chicken Pox) *
Your answer
MMR* (mumps, measles, rubella) *
Your answer
Meningitis *
Your answer
Pneumococcal *
Your answer
Pertussis Booster (Whooping Cough) *
Your answer
Recommended Update at 12 Years: DPT* (diphtheria, tetanus, pertussis) *
Your answer
Hepatitis B *
Your answer
Hepatitis A *
Your answer
Influenza *
Your answer
Medication
Bring enough medication to last or bring your written prescription to order a refill. Prescription meds MUST be in pharmacy containers with appropriate labels; other remedies must be in original container. International staff: translate information to English.
I take medication (including vitamins) on a routine basis. *
If you answered "No" above, write NA in the box below. If you answered "Yes" above, provide the following for EACH medication you take: name of medication, reason for taking it, dose given & when, date started. *
Your answer
General Physical History
Check ALL to which you respond YES. You will need to provide more information in the question below. *
Required
If you checked #16, list where you have sprained, strained, dislocated, fractured, broken, or had repeated swelling or injuries to any body areas. If this doesn't apply, type NA. *
Your answer
If you checked #24, list where you have piercings. If this doesn't apply, type NA. *
Your answer
If you checked #26, list the countries and the length of time spent in them. If this doesn't apply, type NA. *
Your answer
For ALL other items checked above, list the # and explain and/or provide more detail. If you do not need to explain anything, type NA. *
Your answer
Provide the name and office phone number of your physician. *
Your answer
Provide the name and office phone number of your dentist and/or orthodontist. *
Your answer
Check ALL to which you respond YES. You will need to provide more information in the question below. *
Required
If you checked any of the above, please list the # and describe a) the concern and your management plan for addressing it while working at camp, and b) the support needed from your work supervisor to compliment your plan (refer to the essential functions of your job). If this doesn't apply, type NA. *
Your answer
Paying for Health Care
-There is usually no charge for health care provided by the camp's Health Center staff.
-Staff are financially responsible for health care provided by out-of-camp providers.
-If you will be using personal insurance while working at camp, it is your responsibility to know how to access that insurance. BRING YOUR INSURANCE CARD and know how to use it. Consider obtaining pre-authorization if your insurance requires this.
Authorization for Health Care
Parental signature is required for staff less than 18 years of age - contact Minnow if you are less than 18 years of age. This health history is correct insofar as I know. I am capable of performing the essential functions of my job and participating in assigned work duties as noted on this form. I understand my health information will be used by the camp Health Center staff in providing care to me and may be reviewed by my work supervisor.
Type your full name. *
Your answer
Today's date. *
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