2023 Counselor Application

Camp Conquest’s mission is to provide a summer camp program at no cost for pediatric burn survivors. Camp Conquest responds to the needs of pediatric burn survivors by organizing activities to improve campers’ self-esteem, confidence, and physical abilities. Our goal is for our campers to establish friends, network with other burned children, and leave camp with an improved sense of overall well-being. Camp coordinators and staff design therapeutic programs to emphasize key, traditional values such as: Trust, Honesty, Respect, Responsibility, Reliability, Gratitude, and Teamwork.

I understand my legal and ethical duty to maintain and promote the confidentiality and privacy of Camp Conquest’s confidential patient, employee, and business information.

By signing below, I agree to the following:
1. I will be responsible for protecting confidential information (verbal, written, or electronic) used or obtained during my services and for conducting myself in accordance with the applicable HIPAA laws (Health Insurance Portability and Accountability Act).

2. I will not divulge, copy, release, review, alter, or destroy any confidential information.

3. I will never sell any confidential information.

4. I will never post or blog any confidential information, including pictures, video, or anything which can identify children that attend Camp Conquest.

5. I will never place confidential information on a portable electronic media device (i.e., thumb drive, iPad®, Smartphone, laptop).

6. I will not take personal pictures or videos.

7. I will immediately report to Camp Conquest director/staff activities by any individual or entity that I suspect may compromise the confidentiality and privacy of confidential information, so corrective action can be taken.

8. I understand my obligations under this statement will continue after camp is over.

9. I understand I have no right or ownership interest in any confidential information.
During the course of performing my services and thereafter, I will safeguard and retain the confidentiality and privacy of confidential information at all times. I am responsible if I misuse or wrongfully disclose any confidential information.

I understand any inappropriate access, release, or use of confidential information may subject me to disciplinary action and/or appropriate legal action, such as prosecution with law enforcement (civil monetary fines and/or imprisonment).

HIPAA AUTHORIZATION FOR PHOTOGRAPHY/VIDEOTAPING/OTHERIMAGING AND/OR AUDIO RECORDING FOR TREATMENT, EDUCATION, MARKETING, AND/OR MEDIA PURPOSES

This form states that you understand you may be photographed, filmed, broadcasted, published, and/or recorded for the following purpose(s):

Event: Burn Camp at Children’s Harbor

Organization(s): Lake Martin Living, others as determined by Burn Unit Director (i.e. Likely Birmingham News) and other articles as determined by Children’s Hospital Burn Unit Director (i.e., likely Birmingham News)

You give permission for Pediatric Burn Foundation of America dba Camp Conquest (its employees, medical staff, and agents), Children’s Harbor and its representatives, and outside representatives to use your name, picture, voice, stories, or other information you provide to be in newspapers, magazines, television, radio, Internet, or other sources. You release to us all rights to the information collected and waive our liability for actions taken under this permit. This release is effective for a period of ten (10) years unless cancelled in writing to the Children’s Hospital Burn Unit Director to prevent future action. You understand this is voluntary and you will not be paid. By signing below, you indicate you have read and agree to this form.

I consent to signing this application, including the above agreements, electronically. I agree that my electronic signature is the legal equivalent of my manual signature on this application and intend for it to carry the same force and effect as a manual signature.