#UtahCNR 2017 Staff, Nurse & Volunteer Application
Volunteer with the Epilepsy Association of Utah for Camp Neuro Revolution! #UtahCNR #EpilepsyUtah

ABOUT: Camp Neuro Revolution (CNR) is the flagship program for the Epilepsy Association of Utah. CNR offers an amazing opportunity for pre-teens and teens, ages 10 - 18, with epilepsy. Camp is great for youth who face seizures; they can achieve what they'd never believe and have a fantastic time. Some of the activities offered at camp are archery, crafts, cycling, horseback riding, rock wall climbing, ropes course challenge, sledge hockey, swimming, traditional camp activities and more!

STAFF: As a Staff Member you will be expected to stay for the duration of CNR. We ask you to be an example, leader, and mentor for the youth who attend as campers affected by epilepsy, seizures as well as other disabilities. Please anticipate to behave in a respectful and modest manner. We hope to see you engaged with the campers and their activities in an appropriate fashion. We ask that you work in a professional manner with other staff members, volunteers, Epilepsy Association of Utah (EAU) personnel and the Camp Director.

MEDICAL: As a Nurse/Medical Professional you would be expected to provide medical care for all persons in attendance, and distribute medication for all campers and/or persons under the age of 18 years. It is required that you have at least the certification of a Registered Nurse. It is preferred, although not requisite, that you have some experience with children and/or neurological conditions.

VOLUNTEER: As a Volunteer you will be expected to stay for only a few hours to several hours during CNR, depending upon what your schedule allows. You would be expected to act as an example, leader, and mentor for the youth who attend as campers affected by epilepsy, seizures as well as other disabilities. You will be expected to behave in a respectful and modest manner. You will be expected to participate with the campers in an appropriate fashion, and work well with others such as other staff members, volunteers, EAU personnel and the Camp Director. Please plan on leaving children at home or with a babysitter while volunteering at camp.

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Your time volunteered with the EAU is important and precious to us, and 'in-kind,' can be considered as a tax-deductible donation to the EAU as it [the Epilepsy Association of Utah] is a 501 (c)(3) non-profit organization.

Requested information is sent to the Camp Director, and will not be shared, sold, or misused in any way, shape, or form. For any comments, questions, or suggestions about this form, or CNR in general, please contact Nicole via email: info@epilepsyut.org

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Important Dates:
May 31st- Online application due
June 14th-20th - Notification of application status
June 17th - All registration forms due
July 1st - Registration fee and/or other payment due.
July 12th-15th - CAMP!
Name (first and last) *
Birthdate *
Please indicate as follows: mm/dd/yyyy
Primary Phone Number *
Please indicate as a ten digit number: ie) (801) 555-5555
Secondary Phone Number
Please indicate as a ten digit number: ie) (801) 555-5555
Mailing Address *
E-Mail Address *
How did you find out about Camp Neuro Revolution 2017? *
Have you attended Camp Neuro Revolution before? *
Please check all that apply
Required
Why do you want to participate as a staff member or volunteer at Camp Neuro Revolution? *
Which staff position(s) are you most interested in? *
Please check up to three - remember the number of staff members, nurses, and volunteers are contingent on the number of camp participants who register.
Required
Are you willing to submit to a background check to ensure the safety of all who participate at Camp Neuro Revolution 2014 and to protect the mission of the Epilepsy Association of Utah? *
If you chosen as a part of full-time camp staff, you must submit to a background check at your own expense. Please note, paying for your own background check is an in-kind tax-deductable donation to the EAU, as it is a 501 (c)(3) non-profit organization. As a thank you for submitting to a background check, the EAU is providing a FREE individual membership for one year. Utah Law 53-10-108 allows qualifying entities to request Utah criminal history information. Public law 105-251, the Volunteers for Children Act which amended the National Child Protection Act of 1993, was enacted October 9, 1998 to allow these same qualifying entities to request fingerprint-based national criminal history record checks of their volunteers and employees. For more information, please visit http://publicsafety.utah.gov/bci/employees.html
What do you know about epilepsy and other seizure disorders? *
Please explain
Have you seen or otherwise experienced a seizure before? *
Please explain and/or describe if preferred
Have you had any sort of training on how to manage seizures? *
Please explain
Would you be willing to participate in an official Seizure Smart training from the Epilepsy Association of Utah in order to ensure the safety and well being of all participants? *
the EAU provides trained speakers for community presentations to educate the public and help them understand more about epilepsy and its effects. These speakers, also known as "mentors", are directly or indirectly affected by epilepsy. Through education and awareness, the EAU aims to achieve its Mission of mentoring acceptance and understanding in the community. This service is provided at no cost.
Would you be willing to provide transportation for other participants during camp? *
You must have a current drivers license and be willing to submit information to the EAU for insurance coverage purposes.
Do you know (and can competently communicate) any foreign languages or signed languages?
Please list
Who can we contact as a reference, if necessary? *
Please indicate a person or entity who knows of your work/service skills. Include first and last name. Please refrain from using family memeber.
Reference Contact Phone Number *
Please indicate as a ten digit number: ie) (801) 555-5555
Who can we contact in case of an emergency (ICE Contact) ? *
Please indicate a family member or close friend (please indicate relationship) we can contact if an emergency situation should occur. Include first and last name. Please refrain from using out-of-state contacts if possible.
ICE Contact Phone Number *
Please indicate as a ten digit number: ie) (801) 555-5555
If chosen to be a volunteer, staff member or nurse, I will coordinate my availability with the EAU's Camp Director and Volunteer Coordinator. *
Camp will be happening from the afternoon of Wednesday, July 12 through the early afternoon of Saturday, July 15.
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