DAMAGE OR PERSONAL INJURY, INCLUDING DEATH, THAT MAY BE SUSTAINED BY ... attorney's fees, court costs, and other expense
Date Application Sent:
CAMP HOPE TEEN LEADERSHIP FORUM COUNSELOR APPLICATION
Date Application Rec’d: All forms completed:
Yes
Cabin assignment:
Please return all completed forms to: AIDS Foundation Houston – Volunteer Services 6260 Westpark Suite #100, Houston TX 77057 Camp Hope – July 19-25, 2014 (Application due Friday, May 2, 2014) Teen Leadership Forum – June 19-24, 2014 (Application due Friday, May 2, 2014) Name: Address: City/State/ZIP: Mailing address (if different): List the last 3 addresses where you resided:
Date of Birth: _______________ Telephone Home: ( Mobile: (
Age: _______________
)
Work: (
)
Sex: _______________ )
E-mail:
Race/Ethnicity (please circle one):
African-American
Hispanic/Latino
White
Driver's License Number:
State:
Expiration Date:
Make/Model Vehicle:
Year:
License Plate #:
Asian
Other
Social Security #:__________________________
Maiden/Other Name(s): ___________________________________
Marital Status: ____________________________
Spouse’s Name: _____________________________________
Emergency Contact: ___________________________________________ Phone: (
)
T-shirt Size (please circle one):
Relationship: S
M
L
How did you hear about Camp Hope?
Why do you want to volunteer with Camp Hope?
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XL
XXL
XXXL
No
CAMP HOPE TEEN LEADERSHIP FORUM COUNSELOR APPLICATION Do you prefer to work with a specific age group of children? If so, explain specific experience and /or, training with this group:
Previous Camp Experience: (Staff or Camper): Previous Volunteer Work: Child Care Experience: HIV/AIDS Experience: Have you ever been arrested, charged with, convicted of, or received deferred adjudication with respect to any crime (except minor traffic offenses and DUI/DWI) resulting in a fine of less than $200.00 or jail time? If so, explain:
In the last five (5) years, have you ever been convicted of Driving While Intoxicated or Driving While under the Influence? If so, please explain:
Has your driver's license ever been suspended or revoked? If so, explain:
In the last five (5) years, have you ever been convicted of Sexual Offense? If so, please explain:
In the last five (5) years, have you ever been charge or has a report been made against you regarding negligent or abuse of a child? If so, please explain:
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CAMP HOPE TEEN LEADERSHIP FORUM COUNSELOR APPLICATION Have you ever been terminated for cause, asked to resign from a job for misconduct, or suspended or expelled from school? If so, explain:
Occupation: _____________________________________________ Employer's Name: ________________________________________ Address: ________________________________________________ Phone Number: __________________________________________ Can we contact your employer? Yes_____
No_____
Supervisor Name: ________________________________________ Last two employers (please include employment dates):
List three (3) references, at least one (1) professional and at least one (1) personal: NAME
RELATIONSHIP
ADDRESS
Note: We will contact two of the three references. Education: High School attended /Graduation date: College or other attended / graduation date or last year completed: Field of Study: Degree/Certification: Special Skills/Training:
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PHONE NUMBER
CAMP HOPE TEEN LEADERSHIP FORUM COUNSELOR APPLICATION Skill
Yes
Skill
Yes
First Aid Training
American Sign Language
CPR
Musical Instrument
Prevention and Management of Aggressive
Sports
Behavior Life Saving/Lifeguard
Singing
Bi-lingual English/Spanish
Other:
Do you use illegal drugs? ____________
All of the information contained in this application is true and correct to the best of my knowledge. I understand that submitting false or misleading statements on this application or at any other point in the selection process may lead to rejection of my application or termination from placement in the AIDS FOUNDATION HOUSTON volunteer program.
Signature (Guardian signs for minor)
Date
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CAMP HOPE TEEN LEADERSHIP FORUM COUNSELOR APPLICATION RELEASE, WAIVER OF LIABILITY, COVENANT NOT TO SUE AND HOLD HARMLESS AGREEMENT (“RELEASE”) 1.
In consideration for receiving permission to participate in the ______________________________ program for the period of: ___________________________ -- I, FOR MYSELF AND ON BEHALF OF MY SPOUSE, FAMILY MEMBERS, SUCCESSORS, ASSIGNS, REPRESENTATIVES, HEIRS, EXECUTORS AND AGENTS, HEREBY RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE AFH, ITS OFFICERS, SERVANTS, AGENTS AND EMPLOYEES (HEREINAFTER REFERRED TO AS "RELEASEES") FROM ANY AND ALL LIABILITY, CLAIMS, DEMANDS, ACTIONS AND CAUSES OF ACTION WHATSOEVER ARISING OUT OF OR RELATING TO ANY LOSS, DAMAGE OR INJURY, INCLUDING DEATH, THAT MAY BE SUSTAINED BY ME, OR TO ANY PROPERTY BELONGING TO ME, WHETHER CAUSED, EITHER IN WHOLE OR IN PART, BY THE NEGLIGENCE, GROSS NEGLIGENCE OR WILLFUL MISCONDUCT OF THE RELEASEES, OR OTHERWISE, WHILE PARTICIPATING IN THE _____________________________ PROGRAM, OR WHILE IN, ON OR UPON THE PREMISES WHERE THE PROGRAM IS BEING CONDUCTED, WHILE IN TRANSIT TO OR FROM THE PREMISES, OR IN ANY PLACE OR PLACES CONNECTED WITH THE PROGRAM.
2.
I AM FULLY AWARE OF RISKS AND HAZARDS CONNECTED WITH BEING ON THE PREMISES AND PARTICIPATING IN THE PROGRAM, AND I AM FULLY AWARE THAT THERE MAY BE RISKS AND HAZARDS UNKNOWN TO ME CONNECTED WITH BEING ON THE PREMISES AND PARTICIPATING IN THE PROGRAM, AND I HEREBY ELECT TO VOLUNTARILY PARTICIPATE IN THE PROGRAM, TO ENTER UPON THE ABOVE NAMED PREMISES AND ENGAGE IN ACTIVITIES. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OF LOSS, PROPERTY DAMAGE OR PERSONAL INJURY, INCLUDING DEATH, THAT MAY BE SUSTAINED BY ME, OR ANY LOSS OR DAMAGE TO PROPERTY OWNED BY ME, AS A RESULT OF MY BEING A PARTICIPANT IN THE PROGRAM, WHETHER CAUSED, EITHER IN WHOLE OR IN PART, BY THE NEGLIGENCE, GROSS NEGLIGENCE OR WILLFUL MISCONDUCT OF RELEASES, OR OTHERWISE.
3.
I FURTHER HEREBY AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS AND COVENANT NOT TO SUE THE RELEASEES AND EACH OF THEM, FROM ANY LOSS, LIABILITY, DAMAGE OR COSTS THEY MAY INCUR DUE TO MY PARTICIPATION IN THE PROGRAM, WHETHER CAUSED, EITHER IN WHOLE OR IN PART, BY THE NEGLIGENCE, GROSS NEGLIGENCE OR WILLFUL MISCONDUCT OF ANY OR ALL OF THE RELEASEES, OR OTHERWISE.
In signing this release, I acknowledge and represent that:
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CAMP HOPE TEEN LEADERSHIP FORUM COUNSELOR APPLICATION A. I have read the foregoing Release, understand it, and sign it voluntarily as my own free act and deed; B. No oral representation, statements or inducements, apart from the foregoing written agreement, have been made; C. I am at least eighteen (18) years of age and fully competent; and D. I execute this Release for full, adequate and complete consideration fully intending to be bound by same. E. This Release shall be construed and governed according to the laws of the State of Texas. Any suit to enforce the terms of this Release shall be brought exclusively in the courts of Houston, Harris County, Texas. In witness whereof, I have hereunto set my hand and seal this ______ day of ________________________, _________.
Participant Signature: Name Printed: Witness: Witness Name Printed:
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CAMP HOPE TEEN LEADERSHIP FORUM COUNSELOR APPLICATION RELEASE AND INDEMNITY STATEMENT I,________________________________________________, have requested consideration as an AIDS Foundation Houston, Inc. (AFH) camp counselor volunteer. I hereby authorize AFH to check any and all information submitted by me on my application or during the interview process for completeness and accuracy, including but not limited to my current and previous employment, place of residence, education, training, skills, and experience. I further authorize AFH to verify all reference information submitted orally and in writing. I, the undersigned, do for myself, my heirs, executors and administrators hereby remise, release and forever discharge and agree to indemnify AFH and each of its officers, directors, employees and agents harmless from and against any and all causes of action, suits, liabilities, costs, debts and sums of money, claims and demands whatsoever, and any and all related attorney’s fees, court costs, and other expenses resulting from the investigation of my background in connection with my application to become a volunteer member. I hereby release any individual, firm, partnership, corporation, and public official or public entity from any liability on any theory whatsoever providing such information as described herein to AFH.
Signature (Guardian signs for minor)
Date
Printed Name
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CAMP HOPE TEEN LEADERSHIP FORUM COUNSELOR APPLICATION
Date Submitted: __________________ Submitted By: ____________________ Date Rec’d: ______________________
CONSENT FOR CRIMINAL BACKGROUND HISTORY CHECK
I, __________________________________________, hereby give permission for AIDS Foundation Houston (AFH) to obtain information relating to my criminal history record. The criminal history record as received from the reporting agencies may include arrest and conviction data as well as plea bargains and deferred adjudications. I further authorize AFH to conduct local, state and national criminal background checks and understand that a prior charge or conviction of a crime other than a traffic offense constitutes grounds for rejection or dismissal from the camp counselor volunteer program. I also understand that conviction of Driving While Intoxicated/Driving under the Influence within the past five years may affect my acceptance into the camp counselor volunteer program. I understand that this information will be used, in part, to determine my eligibility for a camp counselor volunteer position. I also understand that as long as I remain a volunteer with Camp Hope, AFH will repeat the criminal history check at any time. I understand that I will have an opportunity to review the criminal history and a procedure is available for clarification if I dispute the record as received. I, the undersigned, do, for myself, my heirs, executors and administrators, hereby remise, release and forever discharge and agree to indemnify AFH and each of its officers, directors, employees, and agents harmless from and against any and all causes of actions, suits, liabilities, costs, debts, and sums of money, claims and demands whatsoever, and any and all related attorney's fees, court costs, and other expenses resulting from the investigation of my background in connection with my application to become a volunteer member.
Signature (Guardian signs for minor)
Date
Printed Name
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CAMP HOPE TEEN LEADERSHIP FORUM COUNSELOR APPLICATION PARTICIPATION CONSENT I understand and certify that my participation in AIDS Foundation Houston’s Camp Hope program and its activities at Camp For All is completely voluntary. I have familiarized myself with the program and activities at Camp For All in which I will be participating. I recognize that certain hazards and dangers are inherent in these activities, which may include, but not limited to, the activities of horseback riding, high and low elements ropes course, swimming, archery, riflery, and canoeing. I acknowledge that although AIDS Foundation Houston (AFH) and Camp For All have taken safety measures to minimize the risk of injury to camp participants. I also acknowledge that AFH and Camp For All cannot insure or guarantee that the participants, equipment, premises or activities will be free of hazards, accidents or injuries. I recognize the importance of knowing and abiding by the rules, regulations, and procedures for AFH and Camp For All. Further, I have received approval from a doctor authorizing me to participate in the AFH activities at Camp For All. I also agree to inform AFH staff personnel of any activities in which I may not participate.
Signature (Guardian signs for minor)
Date
VOLUNTEER RELEASE I, ___________________________________ , an AIDS Foundation Houston Camp Hope counselor volunteer, understand and agree to abide by all program policies and procedures, including the Code of Ethics and Code of Conduct. I understand that any violation of policies and procedures could result in my termination as a camp counselor volunteer and/or legal action against me. I understand that participation as a volunteer for as a camp counselor is voluntary. I, the undersigned, understand that occasionally accidents occur during camp activities and that participants may sustain serious personal injury and property damages as a consequence thereof. Knowing the risks of camp activities, nevertheless, I agree to assume those risks and by signing this liability release, I intend to legally bind myself, my minor children, my heirs, executors, and administrators. I hereby release and forever discharge AIDS Foundation Houston and Camp For All, and any of their officers, directors, employees, and agents from all claims, causes of action or damages arising out of any injury, illness, or loss of any kind, known or unknown, including but not limited to injuries to property or person, to me during or related to my attendance at AIDS Foundation Houston and Camp For All. Signature (Guardian signs for minor)
Date
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CAMP HOPE TEEN LEADERSHIP FORUM COUNSELOR APPLICATION AUTHORIZATION TO BE PHOTOGRAPHED (Please check one)
Full Consent
I do give AIDS Foundation Houston and Camp For All the right to interview and/or to take photographs, audio or audiovisual recordings of me to be used in promotional, educational or fundraising materials including, but not limited to videotapes, pamphlets and brochures. I understand my name may be used in connection with these materials. By signing this media release, I intend to legally bind myself, my minor children, my heirs, executors and administrators. AIDS Foundation Houston and Camp For All shall have the right to use photographs or other images of me in promotion, educational or fund-raising materials. I acknowledge that AIDS Foundation Houston and/or Camp For All shall have all rights of copyright in and to such photographs and videotapes and may use such copyright fully. I also hereby release AIDS Foundation Houston and Camp For All and its officers, agents and employees from all liability connected with the taking and use of these materials as is authorized by AIDS Foundation Houston and Camp For All. In addition, I waive all rights, interest or claims for payment in connection with any exhibition or release of these materials. This consent is voluntary, and I give it in the interest of public information, education, the furtherance of the goals of these institutions, or other lawful purposes. I acknowledge that I have legal authority to sign this form on behalf of the name is mentioned above. Signature (Guardian signs for minor)
Date
OR
Limited Consent
I do not wish to be photographed, recorded on audio tape, videotape, and/or film except for the group photograph to be shared with all campers, parents/guardians, volunteers, and Camp staff. Signature (Guardian signs for minor)
Date
NOTE: This release is valid for three years from the date listed below.
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CAMP HOPE TEEN LEADERSHIP FORUM COUNSELOR APPLICATION MEDICAL INFORMATION & RELEASE FORM
Name (print full name)
In reference to my participating in Camp Hope, a program of AIDS Foundation Houston, I grant permission to AIDS Foundation Houston and it’s agents to exercise the following: To apply individualized assessments, based on history and physical examinations, appropriate supportive care, and treatment plans for any acute and chronic medical problems. To administer prescribed medications, as documented below and any other therapy that would be indicated and available for prevention and/or treatment of any medical problems, depending on each case as determined by the Medical Staff. In cases of emergency, to perform and provide access to medical and surgical emergency services, that may include transport to a medical facility off the campgrounds, as determined by the Medical Director. To apply all of the above and the standards of medical care and safety during the bus transportation to and from Camp, and during any events associated with AIDS Foundation Houston, Inc. I understand that my participation is voluntary. I also agree that in the event of any injuries to me from my participation in any program activities, I will not hold responsible the AIDS Foundation Houston, Camp For All, Children’s Medical Center (Dallas), University of Texas Medical Branch (Galveston), University of Texas Health Science Center (Houston), Texas Children’s Hospital (Houston), Cook Children’s Health Care System (Ft. Worth), University of Louisiana Monroe, The University of Mississippi Medical Center, Broward Health (Ft. Lauderdale), University of Arkansas for Medical Sciences, LSU Health Baton Rouge, LSU/Tulane in New Orleans and their professional staff, employees, volunteers, and medical staff. I also understand that it is my sole responsibility to pay for any and all medical expenses that may be incurred during my participation at Camp Hope. My signature below acknowledges my voluntary authorization for my participation in any and all activities. By signing this form, I understand and consent to all of the above.
Signature (Guardian signs for minor)
Date
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CAMP HOPE TEEN LEADERSHIP FORUM COUNSELOR APPLICATION CONFIDENTIALITY POLICY PRACTICE: AFH staff will protect client confidentiality by obtaining specific written permission from the client to release any information (including client status) to any person or agency for any reason. ANY ASSOCIATION OF THE CLIENT’S NAME WITH YOUR NAME AND/OR AGENCY AFFILIATION THAT IS DISCLOSED TO ANY THIRD PARTY COULD CONSTITUTE A RELEASE OF CONFIDENTIAL INFORMATION (HIV DIAGNOSIS). This includes, but is not limited to, written and verbal communication and photographic images. All case information must be safeguarded against any possibility of disclosure to unauthorized persons, even anonymous descriptions of situations or circumstances. (a) No information regarding any case should be talked about in public, regardless of how “harmless" or generic it might be. This applies to conversations in person or by public phone, with other staff members or volunteers, or service providers. (b) Client names or other identifying material must be discussed in private offices only. Care should be taken to avoid talking about a client’s case (c) If you encounter a client in public, exercise some discretion by “hanging back” a bit to allow the client to speak to you or choose not to. The client may find it very difficult to explain who you are to others in his or her company. ATTACHMENT: Texas Health Code 81.103. Confidentiality; Criminal Penalty. My signature indicates my understanding of the AFH policy and the Texas Health Code 81.103.
Signature (Guardian signs for minor)
Date
Associate Camp Director
Date
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CAMP HOPE TEEN LEADERSHIP FORUM COUNSELOR APPLICATION ATTACHMENT: Texas Health Code 81.103. Confidentiality; Criminal Penalty. (a) A test result is confidential. A person that possesses or has knowledge of a test result may not release or disclose the test result or allow the test result to become known except as provided by this section. (b) A test result may be released to: (1) The department under this chapter; (2) A local health authority if reporting is required under this chapter; (3) The Centers for Disease Control of the United States Public Health Service if reporting is required by federal law or regulation; (4) The physician or other person authorized by law who ordered the test; (5) A physician, nurse, or other health care personnel who have a legitimate need to know the test result in order to provide for their protection and to provide for the patient's health and welfare; (6) The person tested or a person legally authorized to consent to the test on the person's behalf; (7) The spouse of the person tested if the person tests positive for AIDS or HIV infection, antibodies to HIV, or infection with any other probable causative agent of AIDS: (8) A person authorized to receive test results under article 21.31, Code of Criminal procedure, concerning a person who is tested as required or authorized under that article; and (9) A person exposed to HIV infection as provided by Section 81.050. (c) The court shall notify persons receiving test results under Subsection (b)(8) of the requirements of this section. (d) A person tested or a person legally authorized to consent to the test on the person's behalf may voluntarily release or disclose that person's test results to any other person, and may authorize the release or disclosure of the test results. An authorization under this subsection must be in writing and signed by the person tested or the person legally authorized to consent to the test on the person's behalf. The authorization must state the person or class of persons to whom the test results may be released or disclosed. (e) A person may release or disclose a test result for statistical summary purposes only without the written consent of the person tested if information that could identify the person is removed from the report. (f) A blood bank may report positive blood rest results indicating the name of a donor with a possible infectious disease to other blood banks if the blood bank does not disclose the infectious disease that the donor has or is suspected of having. A report under this subsection is not a breach of any confidential relationship. (g) A blood bank may report blood test results to the hospitals where the blood was transfused, to the physician who transfused the infected blood, and to the recipient of the blood. A blood bank may also report blood test results for statistical purposes. A report under this subsection may not disclose the name of the donor or person tested or
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CAMP HOPE TEEN LEADERSHIP FORUM COUNSELOR APPLICATION any information that could result in the disclosure of the donor's or person's name, including an address, social security number, a designated recipient, or replacement information. (h) A blood bank may provide blood samples to hospitals, laboratories, and other blood banks for additional, repetitive, or different testing. (i) An employee of a health care facility whose job requires the employee to deal with permanent medical records may view test results in the performance of the employee's duties under reasonable health care facility practices. The test results viewed are confidential under this chapter. (1) A person commits an offense if, with criminal negligence and in violation of this section, the person releases or discloses a test result or other information or allows a test result or other information to become known. (2) An offense under this subsection is a Class A misdemeanor.
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CAMP HOPE TEEN LEADERSHIP FORUM COUNSELOR APPLICATION STAFF/CAMPER CONTACT POLICY
AIDS Foundation Houston pledges to put campers and Counselor–In–Training (CIT) in the company of the most trustworthy and appropriate adults we can recruit – counselors who are best suited to the task of caring for our campers. The efforts we put into screening and selecting our staff is part of that pledge. We expect campers, CITs and counselors to develop close relationships with one another that are healthy and beneficial to all. However, at camp, staff and CITs work with campers in the context of a visible, well supervised environment that has many built-in checks and balances. Because post camp communication occurs outside the supervision of AIDS Foundation Houston the following guidelines have been put into place as they pertain to counselor and CIT contact with campers. (a) CITs will be viewed as AFH volunteers as it pertains to Camp Hope only. Contact with other volunteers will be encouraged for cabin/camp themes and camp activities/planning. (b) When it comes to exchanging contact information (counselor or CIT) with a camper, the camper’s parent/caregiver must give AIDS Foundation Houston written permission prior to any post-camp communication. This includes giving or receiving a postal address, email or IM address, cell phone number, social networking profile, weblog, or any other contact information. (c) AFH volunteers (counselors and CITs) are asked not to engage in any form of social networking (Facebook, MySpace, Twitter, Instagram, Snapchat, etc.) with any camper or participant of Teen Leadership Forum who is considered a minor (under the age of 18) unless the minor’s parent/caregiver has previously authorized such contact. Any counselor or CIT who violates any these post-camp communication policies will be terminated and must leave camp immediately. Additionally, the individual may not come back to camp in any capacity, and may even have to answer to the police or other law enforcement authorities.
In signing this form, I certify that I have read and understand the above policies.
Signature (Guardian signs for minor)
Date
Print Name
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CAMP HOPE TEEN LEADERSHIP FORUM COUNSELOR APPLICATION PARENTAL CONSENT (To be completed by any applicant under 18 years of age) AIDS Foundation Houston (AFH) is a not-for-profit corporation committed to improving the quality of life in the greater Houston community through HIV\AIDS education, social services, health care and volunteerism. AFH volunteer department offers volunteer opportunities in both direct and indirect client services. After a volunteer interview and completion of AFH training, certified teens will be asked to volunteer approximately (10) hours per month on a mutually agreed team assignment.
PARENTAL CONSENT: I give my consent for my son\daughter to participate in the AIDS Foundation Houston volunteer training program. If my son\daughter is certified upon completion of training, I give my consent to his\her serving as an AIDS Foundation Houston volunteer. I release AIDS Foundation Houston, its representatives, Board of Directors, and staff from any and all liability for the actions of my son\daughter\ward while serving as a volunteer. I further release AIDS Foundation Houston, its representatives, Board of Directors and staff from any and all liability for actual bodily injury, psychic injury or illness of my son\daughter\ward arising from his\her service as a volunteer.
Signature of Parent\Guardian
Date
Phone Number – Home
Work
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