PSW Application
First Name *
Your answer
Last Name *
Your answer
PSW Email Address *
Your answer
Street Address *
Your answer
Suite/Apartment Number
Your answer
City *
Your answer
Country *
Your answer
Postal Code *
Your answer
Primary Phone Number *
Your answer
Secondary Phone Number
Your answer
Sex *
Name of Camper you are supporting *
Your answer
Relationship with Camper *
Your answer
Have you met the camper before? *
Have you worked together before? *
Please summarize any experience you have working with the Camper
Your answer
Is the camper in a group home? *
Are you employed by a group home?
Supervisor's Name
Your answer
Phone Number of Supervisor
Your answer
Please list all previous experience as a camp staff, volunteer or camper at any camp.
Your answer
Reference Name *
Your answer
Reference Position/Title *
Your answer
Reference phone number *
Your answer
Please specify any special food or diet considerations including any allergies you might have
Your answer
Personal Health Number *
Your answer
Date of Birth *
Your answer
General health status?
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Have you had or been exposed to a serious/communicable illness in the past? *
If yes to above, please specify (i.e. Hepatitis, HIV, TB, bronchitis etc)
Your answer
Do you have any allergies? *
If you do have any allergies, please list and give types of reactions
Your answer
Are you taking any prescribed medication? *
If yes to above, please specify
Your answer
Please list all immunizations and dates given
Your answer
Next of Kin/Emergency Contact name? *
Your answer
Emergency contact phone number? *
Your answer
Relationship of emergency contact? *
Your answer
What is the status of your Criminal Record Check? *
I have read and agree to the above PSW Liability Waiver *
Is there any additional information that you would like to share?
Your answer
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