Transportation: I am assured that any activity requiring transportation, via moving vehicle, will have a driver, 21 years of age or older, and I release that driver from any responsibility should there be an accident in which I am injured.
Promotional Materials & Media Coverage: Full permission and authority is granted to Camp Smile-A-Mile and its representatives to use my voice recording, image and to use, publish and release for publication, advertisement or promotion (newsletter, camper brochure, flyer, television, magazine, radio, promotional film, or website/webpage) concerning the Camp Smile-A-Mile program. My name may be used by Camp Smile-A-Mile with the understanding there will be no exploitation of me, and any photographs so used should conform to standards of good taste. Camp Smile-A-Mile respects the privacy of its participants and does not allow unauthorized visitors to photograph the camp or participants.
Medical Permission & Release: I meet all of the minimum physical qualifications and I do not have any limitations that would hinder my ability to safely perform any of the duties or essential functions of a Camp Smile-A-Mile volunteer counselor. The health history I have listed on my medical form is correct as far as I know, and I hereby give my permission for the Camp Medical Staff, when necessary, to administer first aid treatment and to dispense medication to me. In the event that my next of kin cannot be reached in an emergency, I hereby give my permission to the licensed physician, dentist or surgeon selected by Camp Smile-A-Mile, to hospitalize, secure proper treatment for, and to order injection, x-rays, anesthesia, medical, dental or surgical diagnosis or surgery for me as deemed necessary. Further, I acknowledge that certain activities at Camp Smile-A-Mile have an increased risk of injury. Therefore, I hereby release and discharge, Camp Smile-A-Mile, its corporate entity, and all of its agents, representatives, employees (paid and voluntary), and all other parties in interest, from all claims, demands, grievances and causes of action of every kind whatsoever, including, but not limited to, all liability from damages of every kind, nature and description, which may arise from or out of injury occurred by myself while in attendance of this camp session, activity or trip. I agree that any medical/surgical emergency is my financial responsibility.
Camper Confidentiality: All information regarding campers is highly confidential. I agree to never release any information, regarding Camp Smile-A-Mile campers, unless given permission by Camp Smile-A-Mile and camper’s parent.
Release of Liability: I hereby release and discharge, Camp Smile-A-Mile, staff, Board of Directors, volunteers and their legal heirs, from all claims, demands, grievances and causes of action of every kind, nature or description, which may arise from, or out of injury by me while in attendance of the Camp Smile-A-Mile camp session/activity.
Personal Property: Camp Smile-A-Mile accepts no responsibility for the loss, damage, or theft of your property.
Emergency Info: If my emergency contact(s) during camp, leaves his/her place of residence or work; I will advise the camp administration where he/she can be contacted in case of emergency.
Participation Agreement: I agree to arrive at the camp program at the specified time and remain through the end of the session and abide by all rules and regulations set forth by Camp Smile-A-Mile, including those listed in the staff manual. |
Are you a US Citizen?
Yes
No
Have you ever used another name?
Yes
No
If yes, please give name and state where the name was used and explain why:
Have you ever been convicted of a felony?
Yes
No
Have you ever been convicted of child neglect, abuse or molestation?
Yes
No
Have you ever been fired from a paid or volunteer position?
Yes
No
If you answered yes, to any of the above questions, please explain below in a statement including convictions, dates & circumstances.
I understand that untrue, misleading, or omitted information herein or in other documents may result in dismissal, regardless of the time of discovery by Camp Smile-A-Mile. I acknowledge that I have read and understand and will accept all terms and conditions listed above pending my acceptance as a Camp Smile-A-Mile volunteer.
I agree the statement above is a true statement.
You can not submit this application without agreeing to the above statement. |