Camp John Marc · Returning Volunteer

Contact Information

I am a:

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Weekend Camp Volunteer (Spring & Fall)

SUMMER Side/leadwalker

Name

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First Name

Last Name

Middle Name

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Email

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Verify Email

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Current Phone Number

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Date of Birth

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(mm/dd/yyyy)

Marital Status (mark N/A if this does not apply)

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Spouse's Name (mark N/A if this does not apply)

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First Name

Last Name

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Length of Time Resided

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Residential History (mark N/A if this does not apply)

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Please list areas you have lived since age 16. City, State, How long did you live at this address (e.g. June 2010-August 2011)

Emergency Contact

Emergency Contact Name

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First Name

Last Name

Emergency Contact Phone Number

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Emergency Contact Relationship to You

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Activity Areas

Please complete this section if you are applying to be a weekend camp volunteer.

Weekend Camp Activities

Please check the activity areas that you have experience with and would feel comfortable leading. Those areas which require a certification are marked with an asterisk.

Fishing

Cooking

Nature

Sports & Games

Weird Science

*Lifeguard

*Challenge Course

*Archery

Please describe your experience with the activities you have marked above.

Please list any current certifications you have.

Medical Information

For your health and safety, please check any medical conditions you currently have.

Allergies

Asthma

Diabetes

Eczema

Hay Fever

Heart Disease/Defect

Other

Please list all medications you currently take.

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Please list any allergies you have.

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Please list any restrictions or limitation you have.

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Do you currently use any illegal drugs?

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Yes

No

Do you feel you can safely lift 50 lbs?

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Yes

No

Have you had your flu vaccination for this season?

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PLEASE NOTE, IN EFFORT TO PROTECT THE HEALTH AND WELL BEING OF OUR CAMPERS DURING THIS INTENSE FLU SEASON, CAMP JOHN MARC IS REQUIRING ALL STAFF AND VOLUNTEERS TO HAVE A FLU SHOT DURING THE MONTHS OF FEBRUARY AND MARCH.

Yes

No

Date of flu vaccination

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(mm/dd/yyyy)

Physician's Name

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First Name

Last Name

Physician's Phone

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Current Application Information

Except as noted below, all information in my previous application is correct and current as of the date of this application. This includes any information related to being fired or terminated from any job; suspended or required to withdraw from school; charged with any felony offense, regardless of type; accused of, charged with, or convicted of any crime, including child molestation, any crime endangering a child, involving the use of weapons, violence, arson, or public indecency; charged with a DUI, DWI, or other motor vehicle offense; possession of any controlled substance within the last five years, or for other than a first offense; residing in the same premises as a Registered Sex Offender. If anything changes prior to my volunteer experience at Camp John Marc, I will notify the Executive Director.

Updated Application Information

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Background Check Verification Release Statment

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By checking this box, I agree to submit a background check when it is requested of me.

Electronic Signature

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Date

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(mm/dd/yyyy)