Supporting comprehensive health care services for
Children with Cancer and Blood Disorders

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973-761-0422
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The Valerie Fund's Camp Happy Times Counselor Application

2014 Dates: August 18th-24th Application Deadline: March 15th

Camp Happy Times Volunteer Information - Returning Volunteer

Note: If you did not attend CHT in 2013, please complete the New Counselor Application.  Thank you!

Camp Happy Times counselors are all volunteers.  Applicants for CHT positions are carefully screened each year prior to acceptance for that year’s camp session.  Although we value the intentions of each applicant, positions are filled with the best candidates based on the needs of the camp and individual strengths and expertise.

Mission
Camp Happy Times promotes friendship, independence and a spirit of cooperation for pediatric cancer patients and survivors aged 5-21.  Our philosophy is to provide a recreationally therapeutic environment that engages participants while building self-esteem, confidence, trust and friendship.

Volunteers
The role of the counselor is complex and demands emotional and physical stamina for a rigorously scheduled week.  Counselors encourage the campers to take on the challenges of various daily activities at camp while ensuring their safety and comfort.  A fully staffed infirmary addresses any medical issues or concerns during the week of camp.

Qualifications

Monday, August 18th (by 10am) – Sunday, August 24th, 2014 (until 1pm)

Application Guidelines– Please read carefully

Camp Happy Times
2101 Millburn Avenue
Maplewood, NJ 07040
Fax to: 973-761-6792 Attn: Camp Happy Times 
Scan and Email to: camphappytimes@thevaleriefund.org

Questions?  Visit our website at www.thevaleriefund.org/camphappytimes or email us at camphappytimes@thevaleriefund.org

Personal and Medical Information

All medical information is maintained under the supervision of the Infirmary Medical Supervisor,
Camp Happy Times, and is protected by Federal Confidentiality Laws.

Please complete ALL current information on this page.

Last Name* A value is required.
First Name* A value is required.
Gender* Please make a selection.
Date of Birth* A value is required.
Age* A value is required.
Home Address* A value is required.
Apartment
City* A value is required.
State* A value is required.
Zip* A value is required.
Home Phone* A value is required.
Cell Phone* A value is required.
Email Address* A value is required.
Preferred Age Group of Campers (Preferences are not guaranteed)*
T-Shirt Size*
Pants Size*
Which is the best way to contact you? (Select One)*
What is the first year you attended CHT?* A value is required.
The role of a CHT volunteer is complex as it demands emotional and physical stamina for a rigorously scheduled week. Are you physically, emotionally and cognitively capable of caring for children aged 5-21 who have or have cancer in a camp setting?* Please make a selection.
1. Can you commit to attending volunteer orientation at the Westminster Hotel on Sunday, July 27, 2014 from 10am – 4pm?* Please make a selection.
2. Can you dedicate a week of your time for Camp Happy Times 2014 from Monday, August 18th – Sunday, August 24th?* Please make a selection.
Have you ever had the chickenpox (varicella)?*


Please make a selection.
Year of Vaccination:
Have you had a tetanus vaccination?*


Please make a selection.
Year of Vaccination:
Have you ever had Measles vaccination (MMR)?*


Please make a selection.
Year of Vaccination:

Have you ever had your Flu vaccination?*




Please make a selection.
Year of Vaccination:
I affirm that all information provided is accurate and true. I understand that any falsification of any information will immediately terminate my application and further opportunities with The Valerie Fund and Camp Happy Times.

In the event of a medical or surgical emergency, I herby authorize the Licensed Medical Staff at Camp Happy Times to render to me or arrange for me to receive any and all treatment deemed advisable by them and to be rendered under the supervision of medical personnel. I also understand that I am responsible for any cost incurred for such treatment that any existing insurance may not cover.
Social Security Number* A value is required.
Driver's License Number* A value is required.
DL State* A value is required.
Place of Employment* A value is required.
Address of Employment* A value is required.
City* A value is required.
State* A value is required.
Zip* A value is required.
Current Position* A value is required.
Years of Employment* A value is required.

Medical Information

All medical information is maintained under the supervision of the Infirmary Medical Supervisor, Camp Happy Times, and is protected by Federal Confidentiality Laws.

Full Name of Emergency Contact* A value is required.
Relationship to Emergency Contact* A value is required.
Emergency Contact Home Number* A value is required.
Emergency Contact Cell Number* A value is required.
Emergency Contact Work Number* A value is required.
Primary Care Physician Name* A value is required.
Primary Care Physician Phone Number* A value is required.
Physician Address* A value is required.
Physician City* A value is required.
Physician State* A value is required.
Physician Zip* A value is required.
Name of Primary Medical Insurance Provider* A value is required.
Group Number* A value is required.
Policy Number* A value is required.
Insurance Phone Number* A value is required.
Address* A value is required.
City* A value is required.
State* A value is required.
Zip* A value is required.
Are you currently under the care of your physician for any medical condition or disorder?* Please make a selection.
Please list any medical conditions since 2003
Surgeries / Reasons for Hospitalizations
Heart Disorder or Condition or Chest Pain?* Please make a selection.
Back or Neck Injury?* Please make a selection.
Cancer? (even as a child)* Please make a selection.
High Blood Pressure?* Please make a selection.
Kidney or Liver Disease?* Please make a selection.
Other?
Please list any medication(s) you are currently taking:
Are you allergic to any medications?* Please make a selection.
Please list the medications you are allergic to and the reaction you had below
Are you allergic to any food or substances?* Please make a selection.
Please list the food(s) and substance(s) you are allergic to and the reaction you had below

Volunteer Terms Agreement

I agree to the Volunteer Terms Agreement* (read) Please make a selection.
I agree to the Volunteer Conduct Guidelines* (read) Please make a selection.