Georgia PKU Connect, Inc. · Camp Connect 2022 Volunteer Application

Your Contact Information

Name: *

First Name

Last Name

Phone Number: *

Email: *

Verify Email *

Address: *

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

County (Enter Georgia County of Residence or "Out of State"): *

Volunteer Details

Birthdate: *

(mm/dd/yyyy)

Gender

T-Shirt Size: *

Youth Small

Youth Medium

Youth Large

Adult Small

Adult Medium

Adult Large

Adult XL

Adult 2XL

Adult 3XL

Do you have any medical diagnosis or medical concerns? *

(multiple answers can be selected)

No

PKU

FAOD

Other

If other please name:

Do you have any allergies (medicinal, dietary, environmental) or other dietary restrictions? If no, write N/A? *

Do you have any special interests or skills?

This information helps us match your interests/skills with volunteer activities at camp.

Is there anything else we should know to make your weekend great?

Health Insurance

This information is required in case of an emergency.

Form of Payment *

Self Pay

Private Insurance

Medicaid

Medicare

SCHIP

TRICARE

VHA

IHS

Medicaid/Medicare/Other Govt Health Program Number (if applicable):

State (if Medicaid or Medicare):

CIDC Number (if Medicaid):

Insurance Company Name (for Private Insurance):

Member ID # (for Private Insurance):

Group # (for Private Insurance):

Insurance Company Phone Number:

In case of emergency please notify: *

Please enter full name (first and last)

Emergency Contact Phone Number: *

Relationship (Mother, Father, Grandmother, Aunt, Friend, etc.): *

Acknowledgement *

I certify all insurance information provided is complete and accurate.

Background Checks *

All counselors/volunteers are required to have a background check. Please verify your agreement with this requirement.

I agree to a background check

I do not agree to a background check

Thank you for applying to be a volunteer for Camp Connect!

After submitting your volunteer application, you will receive a confirmation email. This email will have a link to view a required Georgia PKU Connect/Camp Twin Lakes Release Form. All volunteers and campers will be asked to sign a copy at check-in on September 9h. A few addition forms and a short training will also be required for volunteers. We'll be in touch to go over everything in detail.

If you have any questions, feel free to email us at camp@georgiapku.org.

After reviewing your application, click the submit button below.

Thank you!