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Camp Aloha Volunteer Application

VOLUNTEER GENERAL INFORMATION
Name*
First Last
Address
Street Address City State ZIP Code
Home Phone
Work Phone
Email*
Date of Birth
Month
Day
Year
Occupation
Employer
Employer Address
EDUCATION HISTORY (HIGHEST DEGREE EARNED)
Name of School
Degree/Date
Month
Day
Year
Course of Study
PROFESSIONAL LICENSE AND/OR CERTIFICATIONS
Type
State
Date
Month
Day
Year
Number
Expiration Date
Month
Day
Year
Type
State
Date
Month
Day
Year
Number
Expiration Date
Month
Day
Year
What experience have you had working with children?*
What are your areas of interest for volunteering? (check your top 3)*
- Cabin Counselor
- Camp Nurse
- Group Helper
- Group Leader
- Lifeguard (Saturday Only)
- Photographer
In what camping/outdoor experience have you participated?*
With what age group do you prefer to work (first choice)*
- 6-7
- 8-9
- 10-12
- 13-18
What age group would be your second choice?*
- 6-7
- 8-9
- 10-12
- 13-18
PERSONAL REFERENCE
Name*
Relationship*
Address*
Phone*
PROFESSIONAL REFERENCE
Name*
Relationship*
Address*
Phone*
EMERGENCY AND MEDICAL INFORMATION
In case of emergency please notify:
Relationship
Address
Day Phone
Work Phone
Please list any medical issues we need to be aware of, including serious allergies:
Please list any medications you are currently taking:
Do you have health insurance?*
- Yes
- No
If yes, give name of company
Policy Number
Policyholder's Name
Doctor's Name and Phone Number
I know of no health reason(s) other than the information indicated on this form that would prevent my participation in any of the Camp Aloha activities.
- I fully agree with this statement.
- I do not agree with this statement.
By typing name and date in this box, I attest that all answers are true and valid.
I authorize Hospice Savannah, Inc., or local media and other professionals assisting Hospice Savannah, to record images of me and conduct interviews with me that may be seen and heard by the general public or used for performance improvement or education purposes. I understand these images may be used for educating the public about Hospice Savannah care or promoting programs and services offered by Hospice Savannah and that I have the right to rescind this consent prior to the use of the recording or film.*
- I fully agree with this statement.
- I do not agree with this statement.
I understand that information regarding Camp Aloha campers, their families, staff and any persons receiving support or services in any capacity is privileged information for use by authorized person(s) only. I will disclose such information only to person(s) authorized to receive such information through the signed consent of patient, family member of affected party. I will not disclose any information to anyone unauthorized to receive this information. I will handle any and all paperwork and forms with proper procedure of control so that no information is accidentally observed or released to any unauthorized person(s). I understand that the casual sharing of camper/camper families/staff information in public places or settings is inappropriate including social media postings (i.e. Facebook, Twitter, etc.).*
- I agree to abide by this statement of confidentiality.
- I do not agree to abide by this statement.
I understand that Camp Volunteer Orientation is required of all first-time volunteers and encouraged for returning volunteers.*
- Yes
- No
I understand that a criminal background check is required of all camp volunteers unless currently employed by Hospice Savannah and authorize Hospice Savannah to conduct this check upon my completion of the proper authorization form.*
- I agree with this statement.
- I do not agree with this statement.
Camp Volunteer T-Shirt Size*

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Hospice Savannah, Inc.
1352 Eisenhower Drive
Savannah, GA 31406
912.355.2289

Mailing address:
P.O. Box 13190,
Savannah, GA, 31416

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Camp Aloha Volunteer Application

VOLUNTEER GENERAL INFORMATION

EDUCATION HISTORY (HIGHEST DEGREE EARNED)

PROFESSIONAL LICENSE AND/OR CERTIFICATIONS

PERSONAL REFERENCE

PROFESSIONAL REFERENCE

EMERGENCY AND MEDICAL INFORMATION