Hospice of Frederick County

CAMP JAMIE VOLUNTEER APPLICATION ALL INFORMATION IS STRICTLY CONFIDENTIAL Although not all fields are required we ask that you please fill out as much of this form as possible to simplify the recruitment process should you qualify. Thank you.
	* = Required
* Name:
* Address:
County in which you reside:
* How long have you lived at this address:	ex. 2 years
If less than a year, give previous address:
* Telephone Number (H):	410-123-1234
Telephone Number (W):	410-123-1234
* Birthdate:	ex. 01/01/1980
* Age:	ex. 50
Gender:	Male Female
Ethnic Background:	(optional)

Education

High School Attended:
Year Completed:	ex 1995
Collage Attended:
Year Completed:	ex 1995
Degree:

Employment

First Job:
From:	ex. 01/01/2003
Until:	ex. 01/01/2003

Second Job:
From:	ex. 01/01/2003
Until:	ex. 01/01/2003

Third Job:
From:	ex. 01/01/2003
Until:	ex. 01/01/2003

Volunteer Experience

Agency or Organization:

Physical Limitations:	Yes No
If yes explain:
History of Emotional Disturbances:	Yes No
If yes explain:
Are you available for the entire weekend:	Yes No
Are you authorizing Hospice to conduct a background check:	yes no

Death History

Relationship to deceased:
Year of death:	ex 1995 Age:
Cause of death:

Relationship to deceased:
Year of death:	ex 1995 Age:
Cause of death:

Relationship to deceased:
Year of death:	ex 1995 Age:
Cause of death:

Relationship to deceased:
Year of death:	ex 1995 Age:
Cause of death:

Position you would like to hold at camp:

have you ever volunteered at Camp Jamie:	yes no
If yes in what capacity:
What experience do you have working with children:
Any experience at other children's camps:	yes no
If yes, when and where:
Why do you wish to volunteer at Camp Jamie this year:
Hobbies:

What is your T Shirt size:

Health History
Person to notify in an emergency:
Relationship:
Address:
Daytime Phone:	410-123-1234
Evening Phone:	410-123-1234

Please check those that apply:	Allergies
	Emotional Problems
	Wears Contact/Glasses
	Asthma
	Hearing Impairment
	Heart Disease
	Seizures
	Physical Limitations
	Diabetes
	Motion Sickness
	Other

Please explain any items that were checked or indicate any other useful information regarding your health:

Are you currently under a physician's care for a medical problem:	Yes No

Are you restricted from participating in any physical activity:	Yes No

I know of no health reasons, other than information indicated on this form, why I should not participate in any of the Camp Jamie activities.

* Digital Signature: (type your name)
* Date:

Authorization for Emergency Medical Treatment

Should a medical emergency arise during my participation in Camp Jamie activity and I am unable to speak for myself, I consent to: 1. The administration of medical treatment and/or surgical procedures deemed necessary by the medical doctor and/or medical facility identified below or chosen by the Camp Jamie Director and... 2. The immediate administration of life-sustaining measures deemed necessary under the circumstances.

* Digital Signature: (type your name)
* Date:

Preferred medical doctor/facility:
Address:
Telephone Number:
Insurance Company:
Policy Number:
PolicyHolder's Name:

STATEMENT OF CONFIDENTIALITY

I understand that information regarding Hospice of Frederick County, Frederick Memorial Hospital, patients, their families and/or significant others, and any persons receiving support or services in any capacity is privileged information for use by and with authorized persons only. I will disclose such information only in the discharge of my assigned duties and responsibilities with Hospice or persons authorized to receive such information through the signed consent of patient, family member, or affected party. I will not disclose any information with anyone unauthorized to receive this information. I will handle any and all paperwork and forms with proper procedure of control so that no information is accidentally observed or released to any unauthorized persons. I also understand that the casual sharing of patient care information in public places or settings is inappropriate. I further understand and agree that any violation of this policy is of such critical offense that it will justify my immediate discharge.

* Digital Signature: (type your name)
* Date:

VOLUNTEER PUBLICITY PERMISSION

Upon occasion, videotaping and/or photography may occur during camp activities. This material may be used for future publicity by Hospice of Frederick County, Frederick Memorial Hospital and it’s Board of Directors. In addition, with Hospice staff permission and supervision, the news media may wish to photograph, videotape and/or interview some of the volunteers and children attending camp. Please sign below if you have no objections to being subject to this.

Digital Signature: (type your name)
Date:

If volunteer is under 18 years of age, signature of parent/guardian is required:

Guardian Digital Signature: (type your name)
Date:

References

Name:
Address:
Phone:
In what capacity and how long have you known this person:

Name:
Address:
Phone:
In what capacity and how long have you known this person:

Name:
Address:
Phone:
In what capacity and how long have you known this person:

PINKERTON CONSULTING & INVESTIGATIONS AUTHORIZATION FOR RELEASE OF INFORMATION
In connection with my application for employment, I authorize Pinkerton Consulting & Investigation and their respective agents, to solicit information about my criminal background, and general public records history. I AUTHORIZE, WITHOUT RESERVATION, ANY GOVERNEMNT AGENCY CONTACTED BY PINKERTON CONSULTING &INVESTGATIONS OR THEIR RESPECTIVE AGENTS, TO FURNISH THE ABOVE REFERENCED INFORMATION. I release Pinkerton Consulting & Investigations, their respective employees, agents and government agencies providing information or reports about me from any and all liability arising out of the release of any such information or reports. Pinkerton retains copies of criminal backgrounds for a maximum of thirty days. They are destroyed after that period. I have been advised of my rights under the Fair Credit Reporting Act. If negative information should be presented in my name, I reserve the right to contact Pinkerton Consulting & Investigations for clarification. Hard copy of record is kept for 30 days.
* Full Name:
Other Names Used:
* Current Address:
County:
City:
* State:
* Zip:
* Number of Years at this Address:

Prior Address if less than 2 Years at Current:
Address:
County:
City:
State:
Zip:
Number of Years at this Address:

* Telephone Number (H):	ex. 410-123-1234
* Date of Birth:	ex. 01/01/80
Drivers License #:
State of Issue:
Expiration Date:	ex. 01/01/80
* Social Security Number #:	ex. 555-55-5555

Employment History
Most Recent Employer:
Current Address:
County:
City:
State:
*Signature's may be requested in person at time of interview.

* Digital Signature: (type your name)
* Date: