Volunteer Application

Please fill out the Volunteer Application prior to May 1.

Counselors will attend a training session on Monday, June 10th. Camp is from 9:00 am - 4:00 pm on June 11-13th, 2024.

If you’re over the age of 18, a background check will be required. We will reach out to you.

Email: info@camphotshots.org
Phone: 402-578-3784

Camp Hot Shots
P.O. Box 1731
Council Bluffs, IA 51502

Name

First Name

Last Name

Phone

(###)

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Referred by (optional):

If someone referred you to volunteer for camp, please enter their name below.

T-Shirt Size

Have you previously served as a camp volunteer for Camp Hot Shots?

Yes

What type of camp position are you seeking?

Are you at least 18 years of age?

If the answer to the previous question is NO, please enter your DOB.

Camp Staff under the age of 18 must send an email from their parent or guardian verifying their age to info@camphotshots.org.

YYYY

Do you have any physical or mental disabilities that might prevent you from performing the essential functions of the position for which you are applying?

If YES, do you have specific suggestions as to how we could accommodate your physical or mental disability? Please describe:

Education

Please list your school(s), year graduated, and major (if applicable)

Past Employer #1 (list the past 2 years)

Past Employer Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Past Employer Phone Number

(###)

###

####

Dates Employed Here

Position Held

Reason for Leaving

Past Employer #2

Past Employer Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Past Employer Phone Number

(###)

###

####

Dates Employed Here

Position Held

Reason for Leaving

1) Relevant Camp, Volunteer or Child Care Experience

Please list the activity or organization name, dates involved, supervisor, phone number, and position held (if applicable)

2) Relevant Camp, Volunteer or Child Care Experience

Please list the activity or organization name, dates involved, supervisor, phone number, and position held (if applicable)

3) Relevant Camp, Volunteer or Child Care Experience

Please list the activity or organization name, dates involved, supervisor, phone number, and position held (if applicable)

Reference #1

Provide the names of 3 persons not related to you who have knowledge of your character, experience, and ability.

Reference #1 Phone Number

(###)

###

####

Reference #2

Provide the names of 3 persons not related to you who have knowledge of your character, experience, and ability.

Reference #2 Phone Number

(###)

###

####

Reference #3

Provide the names of 3 persons not related to you who have knowledge of your character, experience, and ability.

Reference #3 Phone Number

(###)

###

####

What contributions do you think you can make at camp in the lives of children living with diabetes?

Describe your experiences with special needs children and/or children with diabetes.

Medications

Please list any medication, dosage, and time of day needed (including insulin)

Do you have any allergies?

If YES to allergies, please describe:

For Medical Staff ONLY. What license do you hold?

Med Staff: What state are you licensed in?

Please send a copy of your license for the state in which camp occurs to info@camphotshots.org.

Med Staff: Has your license ever been revoked?

If YES, please explain:

Med Staff: Do you have malpractice insurance covering your service at camp?

Insurance Company Name

In the event of any need for medical care outside of the camp setting, insurance information specific to you and/or your child may be needed. Please complete the following.

Insurance Company Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Policy Number

Name of Insured Family Member

First Name

Last Name

Insured Member's Place of Employment

Is pre-authorizaiton required?

Pre-authorization Phone Number (if applicable)

(###)

###

####

Consent to Treat

If I have diabetes I hereby give my consent for adjusting insulin dose, performing blood tests, or any medical care deemed necessary by camp physicians and nurses. I also consent to photography and videography to be used to publicize and raise funds for Camp Hot Shots. I will not hold liable Camp Hot Shots, Inc. or any individual associated with the Camp, for accidental injury or illness resulting from attendance and activities at camp. I hereby agree to obey all rules and regulations of Platte River State Park, Camp Hot Shots, Inc. I further agree to obey the instruction of physicians, nurses and assistants pertaining to camp activities, medical needs or practices and all related matters. I also agree to inform the appropriate camp personnel of any matter or activity which I believe to be harmful or which creates the risk of accident or injury to myself or any other participant at the camp.

Electronic Signature of Volunteer

Date of Signature

YYYY

Electronic Signature of Parent Guardian (if patient is under 18 years of age).

Date Parent/Guardian Signature

YYYY