Camp Circle of Love Volunteer Application - Chapters Health System

January 15, 2015
Dear Prospective Camp Volunteer:
Thank you for your interest in LifePath Hospice’s Camp Circle of Love. We are currently planning our
23 rd Annual Camp Circle of Love and would like to invite you to participate.
This year, camp will be held on the weekend of April 24 – April 26, 2015. Cabin volunteers and staff
will need to be available from 2pm on Friday, 4/24 through 1pm on Sunday, 4/26. New volunteers
are required to attend a Camp Orientation. You will select your preferred orientation date and time in
the attached application.
In the event you are interested in participating, we have enclosed the forms to be completed. Please
note that all the forms must be completed whether you are a new or returning volunteer- please do
not leave any form blank. In addition, volunteers will need to complete a fingerprint background
screening prior to final acceptance as a Camp Volunteer. More information is attached detailing this
process.
We would appreciate your completing and returning these documents to us as soon as possible but
no later than March 13 th . All cabin and volunteer assignments will be placed on a first come first serve
basis. Please feel free to call me at (813) 877-2200 if you have any questions.
Again, we appreciate your interest in Camp Circle of Love!
Sincerely,
Ashley Musolino
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2015 Camp Circle of Love Volunteer Information
Thank you for your interest in being a Camp Circle of Love volunteer! The camp committee would
like to give you some information and outline the commitment details so that you will know what you
are volunteering for! We want this to be a great weekend for ALL!
VOLUNTEER ROLE AND RESPONSIBILITIES:
All camp volunteers must be at least 18 years old.
We must complete a national criminal background screening on all camp staff and volunteers.
In order to complete this we ask you for your social security number, race, maiden name, and
date of birth. You will also be required to be fingerprinted as part of your background
screening prior to being able to volunteer at Camp Circle of Love. If you were
previously fingerprinted for Camp Circle of Love, we will be in contact with you whether
you need to be refingerprinted or not. Additional information is attached regarding this
process.
If you would like to be a cabin volunteer, you must be available for the entire weekend. Camp
begins on Friday, April 24 th at 2PM, and ends on Sunday, April 26 th , about 1PM. It is extremely
important that you be settled in by 2PM so that you can attend a mandatory meeting.
Volunteers that will be riding the buses with the children are excused from this meeting and will
get the information presented from their cabin leaders.
It is important that you be there for the entire weekend, because the children need to be with
the same group of counselors all weekend. This helps to promote a sense of security for them
and fosters a setting in which they are comfortable sharing personal information with the
group. As a cabin volunteer, you will be with the children most of the time, including meal and
sleep times. You will be participating in all the activities with your cabin, such as swimming,
arts & crafts, hayrides and much more. We do schedule a break time for each volunteer. If
you are unable to commit to volunteer for the entire weekend, we have plenty of other time
specific or “day only” volunteer opportunities. Please refer to the volunteer application for
further details.
Some camp volunteers will be sleeping in the cabin with the campers of same gender. You
will receive your cabin assignment at orientation. There are showers and “adults only” cabins
for you to use to rest and shower. If you are not sleeping in the cabin with the campers, you
will be given other accommodations to share with other adult volunteers/staff.
Cabin volunteers arrive 3 hours before the campers, so that you have time to get acquainted
with your fellow cabin mates, and get some background information on your campers and pick
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your own bunk! Each cabin is staffed with a cabin leader who will guide the cabin volunteers
and the campers through a meaningful and fun camp experience. Everyone is expected to
pitch in for shared responsibilities, making this the ultimate “team” experience!
The most important requirement for being a camp volunteer is unconditional support to the
campers! Remember that grieving children do not always have the best behavior, and
challenges do pop up from time to time but most can be handled with a little love and
acceptance! Our staff will provide sound and safe guidance every step of the way.
We support family members, significant others and friends volunteering at camp together, but
please stay focused on your primary goal of supporting the children.
We can not guarantee that you will be assigned the same cabin as your friends and/or family
members.
New volunteers are required to attend the Camp Volunteer Orientation. Please select a date
on your application. Returning camp volunteers will receive updated information via e-mail. T-
shirt pick up times for returning volunteers will take place during their orientation times.
Cabin leaders are typically LifePath Hospice staff members or former Camp Cabin Leadersthis
year our goal is to have an assistant leader for each cabin. If you are interested in a leader
role, please mark it on your application, so in the event our staff does not fill these roles, we
will know to contact you for an interview.
Travel time from Tampa to Lakewood Retreat is approximately 45 minutes to one hour.
Unless you are traveling on the bus with the campers, you will need to provide your own
transportation to camp. There is plenty of parking.
Important Dates to Remember:
March 13 th :
March 20 th :
March 30th:
April 8 OR
April 9:
April 24- 26 th :
Applications are due
Deadline for fingerprinting
Cabin Leader Orientation (4-6pm *time subject to change, date will stay)
Camp Orientation (6:00pm – 7:30pm)
Camp Orientation (12:00pm – 1:30pm)
Camp Circle of Love
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Volunteer and Staff Application
Friday, April 24 – Sunday, April 26, 2015
The purpose of this application is to assist us in selecting volunteers and staff for Camp Circle of
Love. In order for you to volunteer, all of the forms must be completed by new and alumni volunteers.
As of August 2010, we have had new regulations which now require us to obtain fingerprints for
all employees and volunteers who provide direct support to clients (including our campers!).
Fingerprints will be completed at no cost to you. However, you will be required to have your
fingerprints done before we are able to assign you to a camp volunteer role. Once we receive your
volunteer application, we will be in contact with you to schedule your fingerprint or verify if we are able
to utilize the fingerprints you may have previously submitted.
New applicants are expected to attend the Volunteer Orientation on either April 8 th or 9 th at the
Azeele Street office. Please choose an option for orientation at the end of this application.
Volunteer Application Checklist
Please ensure that you have completed all of the required materials prior to submitting your
application. This will help ensure that your application can be processed in a timely manner. Contact
Ashley Musolino at (813) 877-2200 if you have any questions or need further clarification.
Thank you for your interest in volunteering at Camp Circle of Love!
CHECKLIST OF ITEMS TO RETURN (Pages 5-9, 11-14, 25 + Copy of Driver’s License)
Completed Volunteer Application
Consent Form (signed)
Volunteer Acknowledgement Checklist (initialed and signed)
Media Release (signed)
Background Affidavit (signed)
Privacy Policy Acknowledgement Form (signed)
Photocopy of Driver’s License (must be able to read ALL information on DL- taking a picture of
it and e-mailing it from a phone is also acceptable and produces the best results)
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Camp Circle of Love 2015 Volunteer Application
Name:
FIRST MIDDLE LAST NICKNAME (for nametag)
Home Phone: __Cell: E-Mail: ______
*Please note: application confirmation and orientation information will be sent by e-mail. Please specify if
you do not have an e-mail address that you check regularly
Address:
City/Zip:
Languages Spoken: English Spanish Sign Language Other:
Employer:
Work Phone:
Occupation:
Emergency Contact:
Relationship:
Emergency Contact Phone:
If this is your first time at camp, how did you hear about this opportunity?
Do you know any children who may be attending camp this year? Yes
No
If yes, please explain relation to the potential camper:
Did you have a loss/death within the past year? Yes No
If yes, do you feel that you are emotionally ready to attend camp?Yes No
Please explain:
Please list any special arrangements/health concerns/diet requirements/ physical
limitations/ allergies (i.e. vegetarian, etc.):
Background Screening Information:
Driver’s License #*
(If none, write none)
State License Was Issued:
*A photocopy of your driver’s license must be attached & readable
Maiden Name:
Other names you have used in past 7 years____ _______ ______
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Your affiliation with LifePath Hospice (check those that apply):
I am LPH/GSH/HPC Staff
First Time Volunteer
Current LifePath Volunteer
Grief Center Volunteer
Camp Circle of Love Volunteer Alumni Camp Brave Heart Volunteer
Previous Camper @ Camp Circle of Love (Year: )
Volunteer Interest
Please select either a cabin role or a support role.
(Every attempt will be made to assign you to your preference; however, we must consider the needs
of the children as priority.)
Cabin Volunteer Roles:
Cabin Leader (Please see cabin leader note on Volunteer Information page 2. Cabin Leaders
must be able to attend a Cabin Leader meeting on March 30 th from 4-6pm.)
Cabin Volunteer (assists Cabin Leaders in all activities; Must be available all weekend)
Cabin leaders and volunteers; please indicate your preference for:
Gender: Boys Girls No preference
Age Group: Younger age group Older age group No preference
Support Volunteer Roles (please check all that apply):
I would like to participate all weekend:
and would like to sleep at camp.
and do not require sleeping arrangements.
I will only be available on Saturday 4/25/15 (Saturday volunteers must arrive at camp no
later than 8am. Activities vary in end time, but all volunteers are invited to stay for dinner and
other camp activities.)
I am a Saturday-only volunteer and I will be staying for dinner
*For Support Volunteers Only:
I would like to assist with:
Land Sports (Human Foosball, Kickball, Horseshoes, etc.)
Pool Activities; Please indicate if you are a Red Cross Certified Lifeguard (Yes
No )
Arts and Crafts
Camp Photographer (must be available all weekend & have digital camera)
Camp Musician (If new to Camp, Lead Musician will contact you regarding need)
Ropes Course
Pet Therapy (We will contact you with requirements & availability)
No Preference
Other:
In addition to the above, I would also be able to:
Assist with transportation of the children (ride the buses) to and from camp. (Bus riders
arrive at the Azeele office no later than 2:30pm Friday and will arrive back around 12:30 on
Sunday)
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New applicants, please answer the following questions:
Please describe your qualifications for and/or experience in working with children:
Please describe any special talents or skills that you may have which may benefit the camp:
Please describe why you want to volunteer at Camp Circle of Love:
I plan to attend the Camp Orientation on (select one):
April 8 (6:00 – 7:30pm) April 9 (12:00 – 1:30pm)
(Camp Orientation will be held at 3010 W. Azeele Street, Tampa, FL)
We appreciate your interest in Camp Circle of Love. You will receive e-mail notification once we
receive your application.
Please return this completed application by March 13, 2015 to:
Attn: Ashley Musolino
LifePath Hospice
3010 W. Azeele Street
Tampa, Florida 33609
Fax: (813) 357-5672 (This fax comes to my secure e-mail, so your information will be safe)
Scan & E-mail: MusolinoA@chaptershealth.org
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Dear Volunteer,
This is a standard form required to release related information to us. We perform this check as part
of our application process for all potential employees and volunteers. Thank you for your
cooperation.
Consent to Request Information
I understand that LifePath Hospice will utilize the services of a consumer reporting agency to obtain
information through investigation.
I understand a consumer reporting agency's investigation may include obtaining information covering
up to the last seven (7) years regarding my references, driving record, character, general reputation,
personal characteristics, Office of the Inspector General, civil and criminal background.
I also understand that before LifePath Hospice takes any action based, in whole or part, on
information obtained in the report, I will be provided a copy of the report and a description in writing of
my rights under the Fair Credit Reporting Act. Such adverse action includes but is not limited to
denial of volunteer status with LifePath Hospice and including discharge from volunteer duties.
I understand if I disagree with the accuracy of any information in the report, I must notify LifePath
Hospice within two (2) days of my receipt of the report. If I notify LifePath Hospice within two (2) days
of the receipt of the report that I am challenging information in the report, LifePath Hospice will not
make a final decision on my volunteer status until after I have had a reasonable opportunity to
address the information contained in the report.
I hereby consent to this investigation and authorize LifePath Hospice to procure a report on my
background as stated above.
Date:
Signature:
Name (please print):
Date of Birth: Social Security Number: (Required)
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Media Release
Upon occasion, videotaping and photography may occur during various Camp Circle of Love
activities, and this material may be used by LifePath Hospice, Inc. (“LPH”) or Chapters
Healthcare, Inc. in future marketing and publicity. In addition, the news media may wish to
photograph, videotape and/or interview participants for news coverage of the Camp Circle of
Love. When LPH knows of such previously scheduled media activities, LPH will inform you
in advance of any details pertaining to such scheduled occasions. If you agree to being
photographed, videotaped and/or interviewed, and/or agree to your child(ren) or ward(s)
identified below being photographed, videotaped and/or interviewed, please mark the
appropriate box and sign below:
I hereby give permission for myself and, if applicable, my minor child(ren) or ward(s)
listed below, to appear in publicity or news coverage regarding Camp Circle of Love,
as described above. I hereby release and discharge LPH and Chapters Healthcare,
and each of those entities officers, directors, employees, volunteers and agents, from
any and all claims and demands arising out of or in connection with the use of the
videotapes or photographs, including without limitation any and all claims for libel or
invasion of privacy.
____ I give FULL permission
____ I DO NOT give permission
____ I give permission with the following EXCEPTIONS:
Signature:
Date:
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Background Screening/Fingerprinting
As of August 1, 2010 we have had new regulations which now require us to obtain fingerprints for all
employees and volunteers who provide direct support to clients.
Fingerprints will be completed at no cost to you. However, you will be required to have your
fingerprints done before we are able to assign you to a camp volunteer role. Once we receive and
process your Camp Circle of Love volunteer application, we will be in contact with you to get your
fingerprint screening completed or, if you have previously been fingerprinted with us, we will confirm
whether we will need for you to be re-fingerprinted. Most of our returning volunteers that have not
remained an active LifePath Hospice patient-family volunteer or staff member will need to be refingerprinted.
We are also required to have you submit a signed affidavit (see attached form) which we will maintain
in your volunteer file in our Human Resource Department. Please complete this form and submit it
with your Volunteer Application.
Thank you in advance for your willingness to complete the necessary screening requirements to
volunteer with us. If you should have questions regarding this process, please contact Scott Cornelius
at 813-357-5603.
Please sign and date both the affidavit & privacy acknowledgement and return it with your
completed application.
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LifePath Hospice
3010 W. Azeele Street, Tampa, FL 33602
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LifePath Hospice
3010 W. Azeele Street, Tampa, FL 33602
Acknowledgment of Receipt and Understanding of Sexual Abuse Policy
I acknowledge that I have received and read the sexual abuse policy and/or have had it explained to me. I
understand that the company will not tolerate any employee, volunteer, board member or third party who
commits sexual abuse. Disciplinary actions will be taken against those who are found to have committed
sexual abuse.
I understand that it is my responsibility to abide by all rules contained in the policy. I also understand how to
report incidents of sexual abuse as set forth in the abuse policy, including retaliating against any
employee/volunteer exercising his or her rights under the policy.
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VOLUNTEER ACKNOWLEDGEMENT CHECKLIST
CAMP CIRCLE OF LOVE 2015
I acknowledge that I have received and read the following documents concerning these specific policies and
procedures listed below and/or have had them explained to me. I understand that it is my responsibility to abide
by all rules contained in each policy. I further understand how to report incidents of policy violation, including
retaliating against any employee/volunteer exercising his or her rights under the policies. I acknowledge that I
have read each agreement, received a copy for my personal reference, understand it and am signing this
acknowledgment of receipt of my own free will.
Please Initial Below:
______
______
______
Code of Conduct
Confidentiality and Security Agreement
Sexual Abuse Policy
_______________________________
Volunteer Printed Name
______________________________
Volunteer Signature
_______________________________
Date
*When returning your application, only include this sheet. Do not include the three forms listed above.
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