Camp Medical and Dietary Staff Application

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DYS Hot Shots Camp is currently accepting applicants to fill available medical and dietary positions.

Please answer all questions to the best of your ability.

Email *

Legal First Name *

Legal Last Name *

Nickname

Gender *

Home Address *

City *

State- Please spell out fully. *

Zip Code *

Phone number *

Email address- Please select one you check often. *

Position you are applying for

Note: This application is only for those interested in being on medical or dietary staff (including dietary interns). If you are interested in another position at camp, visit dys4kids.org/camp-staff/ to fill out the correct application for you

Medical Staff

Dietary

Dietary Intern/Volunteer

Medical Staff- Volunteer

T Shirt Size *

Adult S

Adult M

Adult L

Adult XL

Adult 2XL

Adult 3XL

Adult 4XL

Nutritional Information

Please complete to the best of your ability.

Do you have any allergies? *

Yes

If yes, please specify.

Please indicate any other dietary restrictions you have (Celiac, vegan/vegetarian, etc.)

Education and License Information

Please complete to the best of your ability.

List any certifications held (First Aid, Lifeguard, etc.) *

If you are in school, list school, major and anticipated graduation date (MM/YY).

What license do you hold? *

Nursing

Dietary

Medical

None/Student

Other:

Please provide your license number.

In what state are you licensed?

Has your license ever been revoked? *

Yes

If yes, please explain. *

Have you ever been accused of, convicted of, or had deferred adjudication of medical malpractice? *

Yes

Do you have malpractice insurance covering your service at camp? *

Yes

Availability

Please answer to the best of your knowledge.

Which camps are you interested in attending? *

Little Shots Day Camp in Sylvania, OH- July 10-13, 2023

Little Shots Day Camp in Tecumseh, MI- July 31- August 3, 2023

Middle Shots Resident Camp in Ashley, OH- June 23-26, 2023

Big Shots Resident Camp in Ashley, OH- June 19-23, 2023

Other:

Required

Have you ever attended Hot Shots Camp previously as staff? *

No, I have never attended

Yes, 1-2 years

Yes, 3+ years

Employment and References

Please complete to the best of your ability. Must list professional references- no family or close friends.

Current Employer *

Employer Address *

Employer Phone *

Date of Employment *

YYYY

Reference #1 Name *

Reference #1 Phone Number *

Reference #1 Email *

Reference #1 Relationship *

Reference #2 Name *

Reference #2 Phone Number *

Reference #2 Email *

Reference #2 Relationship *

Reference #3 Name *

Reference #3 Phone Number *

Reference #3 Email *

Reference #3 Relationship *

Additional Information

Please answer to the best of your ability.

Do you have Type 1 diabetes? *

Yes

List any physical restrictions you have. *

Have you ever been convicted of a felony? *

Yes

What is your current vaccination status? *

Not vaccinated

Have received initial vaccine(s) but not booster vacciene

Fully vaccinated- have received all initial vaccines plus booster

Why do you want to attend Hot Shots Camp? *

Liability Waiver

The above information is true to the best of my knowledge. I authorize investigation of all statements herein and release Diabetes Youth Services and all others from liability in connection with same. I understand that if employed, I will be an at-will employee. I understand that untrue, misleading, omitted information herein may result in dismissal, regardless of the time of discovery by Diabetes Youth Services

Waiver: In consideration of Diabetes Youth Services permitting me to participate at Diabetes Youth Services Camp, and acknowledging that activities while at camp have inherent risks, on behalf of my heirs, executors, administrators and assigns, I hereby waive, discharge, and release any and all rights claims for damages, losses or expenses which I may have against Diabetes Youth Service, Recreation Unlimited, Sylvania Park District/Olander Park, ProMedica Farms, or any other camp facility and their management, as well as any other person connected with Diabetes Youth Services Camps or as a result thereof. I hereby give Diabetes Youth Services, their legal representatives or assigns and those acting under their permission and upon their authority, permission to use my picture, and if desired, my name in advertising and in all forms of publicity, without limit as to time. I further release Diabetes Youth Services from any liability for what I might deem misrepresentation of be by virtue of alterations, optical illusions or faulty mechanical reproduction in such advertising and/or publicity.

I further acknowledge that while Recreation Unlimited, Olander Park, and ProMedica Farms have COVID-19 protocols in place, and while DYS staff and volunteers also will be asked to follow COVID-19 protocols, DYS cannot guarantee that I will not contract COVID-19 while at a DYS camp or during registration and transportation to and from camp, and that there is an inherent risk of contracting COVID-19 by attending camp, and I hereby waive any liability against DYS for the same.

If you have any questions please contact:

Cindy Presser
DYS Program Director
419-291-1238
cindy@dys4kids.org

By typing my name below, I understand and agree to all Terms and Conditions. *

Thank you for your interest in Hot Shots Camp! A background check and drug screen are mandatory to be considered a camp staff member. Application deadline is April 15th, 2023. You will be contacted with more instructions after this deadline.

A copy of your responses will be emailed to the address you provided.

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