2024 Counselor Application Step 1 of 5 – Basic Information 20% Name(Required) First Middle Last Date of Birth(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone(Required)Alternate PhoneEmail(Required) T-Shirt Size(Required)SMLXLXXL3XL Application DetailsAre you a new or returning counselor?(Required) New Returning Are you planning to be present for the entire week and serve as a camp counselor?(Required) Yes No What days will you be available?(Required) Which of the following apply to you?(Required) Student Firefighter Junior Counselor (under 18) None of the above Name of School(Required) Name of Department(Required) Name of Family Member Attending Camp(Required) What is your connection to the pediatric burn community?(Required)Please share why you have an interest in being a counselor or volunteer at Camp Conquest(Required) Background InformationNote that all counselors will be required to complete a background check prior to serving at Camp Conquest. More details will be provided after your application has been processed.Have you ever been convicted of a sexually related or child abuse related offense?(Required) Yes No Have you ever been convicted of a felony?(Required) Yes No Please explain any "yes" answers above.(Required) Emergency Contact and Medical InformationEmergency Contact 1 Name(Required) First Last Emergency Contact 1 Phone(Required)Emergency Contact 2 Name First Last Emergency Contact 2 PhoneInsurance InformationPlease choose an option(Required) Upload a copy of my insurance card Enter insurance details manually Insurance Card Upload(Required)Please ensure your upload includes the front and back of your card. Drop files here or Select files Max. file size: 100 MB. Name of Carrier(Required) Name of Insured(Required) Policy Number(Required) Group Number(Required) Basic Health HistoryCheck in which, if any, of the following areas you have health concerns. Eyes (vision, night blindness, etc.) Ears Nose & Throat Abdomen Lungs (asthma, shortness of breath, etc.) Heart Defects High Blood Presure Seizures Bleeding Disorders Headaches or Migraines Nightmares or Sleepwalking Psychiatric Please explain any "yes" answers above(Required)List any surgeries or hospitalizations within the past yearAllergies Bee/ant stings Hay fever Food allergies Latex Medication Other Allergy DetailsPlease describe the allergic reaction (rash, hives, wheezing, etc.) and any additional information such as what foods you are allergic to.Medications Currently TakingMedicationDoseFrequencyRoute (by mouth, cream, injection, inhaler, etc.) Add RemovePlease describe any special dietary needsPlease describe any additional medical information we should know AgreementsTreatment Release(Required)I hereby authorize the medical personnel chosen by Pediatric Burn Foundation of America to secure and administer treatment for myself in the event of a medical emergency. This treatment may include, but may not be limited to transportation, x-rays, routine tests, and other necessary treatments. I also give my permission to allow the Burn Center Camp Nurse to administer over the counter medication, i.e., acetaminophen (Tylenol), ibuprofen (Advil), diphenhydramine (Benadryl), Pepto Bismol, or Anti-Diarrheal medicine as needed at my request. Other medications that might be needed for your treatment include: Head Lice Treatment Shampoo, Bee Sting Swabs (sting relief), or topical ointments/creams such as bacitracin or polysporin, Benadryl cream and Calamine Lotion. I agree to the treatment release.Liability Release(Required)The undersigned, being of legal age, in consideration of attending Camp Conquest which is sponsored by Pediatric Burn Foundation of America, and participating in the programs/activities during camp held on the premises and facilities of Children’s Harbor, Inc., specifically use of Mariners’ Adventure Camp, whether on the actual premises of Children’s Harbor, Inc., or elsewhere its agents, successors, officers, employees, directors, and Board that I, whether individually or in representative capacity, will never institute any suit, action at law, claims or make any claims against Pediatric Burn Foundation of America, its agents, successors, officers, employees, directors, or Board, and volunteers for Camp Conquest who provide transportation to and from camp, for or by reason of any damage, loss, or injury either to person or property developed or undeveloped, resulting or to result, known or unknown, which I, my heirs, executors, or administrators hereafter can, shall or may have for, on or by reason of any matter, cause or things whatsoever, whether arising prior to the Agreement or after this Agreement is executed. In further consideration of the above stated, I hereby agree to indemnity and save harmless Pediatric Burn Foundation of America, its agents, successors, officers, employees, directors, or Board, and volunteers who provide transportation for campers, against any claims for damages, compensatory or otherwise, on the part of me or my heirs, executors or administrators and to reimburse any loss or damages or costs that Pediatric Burn Foundation of America, may have to pay as a result of litigation arising on account of any claims, actions at law or judgments instituted or obtained on behalf of me. I have read this entire Agreement, and fully understanding its terms, covenants, and conditions, have voluntarily signed on behalf of me. I agree to the liability release.Confidentiality and Nondisclosure Statement(Required)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). I agree to the confidentiality and nondisclosure statement.HIPAA Authorization and Medical Release(Required)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 agree to the HIPAA authorization and medical release.Electronic Signature Agreement(Required)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. I agree to the electronic signature agreement.Please type your name as your electronic signature(Required) EmailThis field is for validation purposes and should be left unchanged.
