Adult Staff and Nurse Registration

Staff Application

Applicants must be 22 years old by, June 2019. By Completing this application you affirm under penalty of perjury that the answers to the questions in this form are truthful. You also consent for a criminal background check to be performed on you. Individuals who have ever been convicted of an offense involving the intentional infliction of physical injury upon a child, sexual abuse of a child or child abduction under the laws of this state or any other state, or any persons using illegal drugs are disqualified from volunteering for Special Camps.

Name*

First Middle Last

Date of Birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

T-Shirt Size*

adult small
adult medium
adult large
adult XL
adult 2XL
adult 3XL

Email*

Driver's License #*

Home Phone*

Mobile Phone*

Emergency Contact + Relationship to you*

Emergency Contact Phone Number*

Position Preferred*

Nurse
Activity Leader
Cabin Parent

Can you swim?*

Yes
No

On a level of 1-5, rate your comfort and experience with horses*

1 - I would prefer not to ride horses at camp
2 - No experience and would like to learn
3 - Limited experience but not a trained rider
4 - Have ridden and am comfortable with horses
5 - I am a trained rider

List any special skills or training

examples: - Sign language - Multi-lingual - First aid - Life guard / Water Rescue - E.M.T./Paramedic - Registered Nurse - I've attended Special Camps before

Experience with individuals who have Special Needs*

Describe your experience helping individuals who have special needs.

Personal Health

Please describe any physical, mental, or medical concerns that may effect you during camp. ie: Diabetic, back pain or other physical concerns effecting physical maneuverability, depression or other mental health conditions, etc.

List any prescription or over the counter medication you would bring to camp

Please indicate your preferred camp session*

June 16-21 | Adult Camp
June 9-14 | Youth Camp
I am available either week

NOT RELATED - reference name 1

Reference 1 Phone#

NOT RELATED - reference name 2

Reference 2 Phone#

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Camp Waiver

Thank you for completing the online portion of the Staff Application. Please complete the “Print and Mail” portion of the camp application. Once both forms are returned, you will be considered for camp. The forms can be mailed to our office at 26W684 Lindsey Avenue, Winfield, IL 60190 or scanned and emailed to colleen.scamps@icloud.com