Camp Staff Application: Medical and Dietary

DYS Hot Shots Camp is currently accepting applicants to fill available medical and dietary positions.

To ensure proper consideration, please fill in the information below as completely and accurately as possible.

Personal Information

First Name *

Last Name *

Address 1 *

Address 2

City *

State *

Zip Code *

Cell Phone *

Email Address *

Position Applying For *

T-shirt size *

Education & License Information

List any certifications held (EMT, First Aid, Lifeguard, etc.) *

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What license do you hold? *

If yes, please supply your license number

What state are you licensed?

Has your license ever been revoked? *

Yes

No

If yes, please explain.

Have you ever been accused of, convicted of, or had deffered adjudication of medical malpractice? *

Yes

No

Do you have malpractice insurance covering your service at camp? *

Yes

No

Availability

Which camps are you available? *

Big Shots Resident Camp (June 22 -27, 2020) - Ashley, OH

Middle Shots Resident Camp (June 20-22, 2020) - Ashley, OH

Little Shots Day Camp (July 13-16, 2018) - Sylvania, OH

Have you attended Hot Shots Camp previously? *

Yes, 1-2 years

Yes, 3-5 years

Yes, 5+ years

No, I have never attended

Employment History

Employer

Company Name

Address

Phone

Start Date +

Phone Number

References

Reference 1

Name

Relationship

Email Address

Phone

Reference 2

Name

Relationship

Email Address

Phone

Reference 3

Name

Relationship

Email Address

Phone

Additional Information

Do you have type 1 diabetes? *

Yes

No

Have you ever been convicted of a felony? *

Yes

No

Please list any physical restrictions you may have *

Why do you want to volunteer at Hot Shots Camp? *

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Liability Waiver

The above information is true to the best of my knowledge. I authorize investigation of all statements herein and release Diabetes Youth Serives and all others from liability in connection with same. I understand that if employed, I will be an at-will employee. I understand that untrue, misleading, omitted information herein may result in dismissal, regardless of the time of discovery by Diabetes Youth Services

Waiver: In consideration of Diabetes Youth Services permitting me to participate at Diabetes Youth Services Camp, and acknowledging that activities while at camp have inherent risks, on behalf of my heirs, executors, adminstrators and assigns, I hereby waive, discharge, and release any and all rights claims for damages, losses or expenses which I may have against Diabetes Youth Service, Recreation Unlimited, Sylvania Park District/Olander Park or any other camp facility and their management, as well as any other person connected with Diabetes Youth Services Camps or as a result thereof. I hereby give Diabetes Youth Services, their legal representatives or assigns and those acting under their permission and upon their authority, permission to use my picture, and if desired, my name in advertising and in all forms of publicity, without limit as to time. I further release Diabetes Youth Services from any liability for what I might deem misrepresentation of be by virtue of alterations, optical illusions or faulty mechanical reproduction is such advertising and/or publicity.

If you have any questions please contact:

Morgan McCulough
DYS Program Director
419-291-1238
Morgan@dys4kids.org

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A background check and drug screen are mandatory to be considered a a camp staff member. Upon acceptance of application, you will be given further instructions to complete the background check and drug screen.