2022 Camp Firefly: Staff Application

2022 Camp Firefly

HASDC's Annual Youth Camp for Children Ages 7-14
Submitting a Camp Firefly application DOES NOT guarantee you a Staff position at camp. As space is limited, applications will be reviewed by HASDC and acceptance will be dependent on the order the application is received, qualifications, and that all required forms are complete, accurate, and submitted prior to the deadline.
Please make sure you have all the required Staff information, including health information and documents ready to upload, before completing the application.

You will need to provide and/or upload the following documents:
- Medications: complete list of medications you take (includes but not limited to factor, other prescription meds, over the counter medications, inhalers, etc.)
- Insurance Card: copy of your insurance card, front and back.
- COVID-19 Vaccination: a copy of your COVID-19 vaccination card (full COVID vaccination required for all campers and staff; must be fully vaccinated 2-weeks prior to camp start date).
- Immunization Records: a copy of your immunization records, signed and validated by your primary care physician. The following immunizations/vaccinations are required: DTap (Diphtheria/Tetanus/Pertussis), MMR (Measles/Mumps/Rubella), Measles, Varicella (chicken pox), Polio, Hepatitis A & B, and COVID-19.

Staff Self-Assessment

Are you ready to join our camp staff?
Can you take the time to make a difference?

Since you are inquiring about a camp staff position with HASDC, it means that you possess a caring and compassionate nature. All camp positions require a significant commitment during camp. Sometimes staff with good intentions and great ideas are simply too busy to follow through on their commitment. This can result in a disappointed camper. With this in mind, we are counting on you to follow through with the commitments you make to the camp in addition to the other commitments in your life.

You understand that you will check your personal life upon arrival and fully participate in camp for the entire week. You understand that there will most likely be no cell coverage, no access to email, limited sleep. Please consider this carefully before you apply.

Can you go with the flow?

The physical environment in which we live at camp is different than what we are used to in our everyday lives. In addition to the uniqueness of the physical environment, we continually challenge camp staff to reach new heights of personal growth that will then help them lead campers to the best possible camp experience. Though this unique environment can be challenging, it is part of what makes it such a rewarding experience for staff.

Can you go the extra mile?

At HASDC, we strive to make camp a life-enriching experience for all who attend, campers and staff alike. We strongly urge staff to spend time before camp honing their counseling skills by learning new camp songs, child management techniques, leadership skills, and technical skills. To what length are you willing to go in order to be the best camp counselor, JRC, or general staff person that you can be?

Thank you for considering these important questions. Every staff person is important to the mission of HASDC’s summer camps and the campers rely on YOU for this extraordinary experience. If after answering these questions to yourself, camp seems like it is a good fit for you, then please complete the registration materials by July 22.

Participant Information
Participant’s Full Name *

First Name Last Name
I am applying for the following Staff Position:
Participant is: *

a bleeding disorder patient (includes carriers) unaffected
Date of Birth *

Month Day Year
Age *
Participant's Gender Identity: *

Male Female Non-Binary/Non-Conforming Transgender Other
Participant's Primary Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Participant's Cell Phone Number *
Please enter a valid phone number.
Participant's T-Shirt Size *
Is this your first year at an HASDC camp? *

Yes No

Employment History

Please provide information for your current employer.
Company | Employer *
Start Date *

Month Day Year
Date
End Date

Month Day Year
Date
Position *
Supervisor's Full Name *

First Name Last Name
Employer's Phone Number *
Please enter a valid phone number.
Employer's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Volunteer | Childcare Experience

Please indicate any previous experience below.
Do you have previous camp volunteer or childcare experience? *

Yes No
If yes, please use the space below to describe your experience. Additionally, provide the name of the organization along with your supervisor, relevant dates and the positions you held in the fields below. *
If you selected 'No' above, please put N/A.
Name of Organization
Position Held
Supervisor's Full Name

First Name Last Name
Supervisor's Phone Number
Please enter a valid phone number.
Duration

References

Please provide two professional references. Do NOT list relatives or HASDC staff as references. Suggested references include past employers, co-workers, fellow volunteers, babysitting employers, etc. If you are a returning volunteer to HASDC’s summer camp program, you are welcome to list a fellow volunteer of a prior camp as only one of the two references required. Please note: references will be contacted therefore please verify that contact information is current.
Reference #1
Reference's Full Name *

First Name Last Name
Relationship to Participant: *
Reference's Phone Number *
Please enter a valid phone number.
Reference's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Reference #2
Reference's Full Name *

First Name Last Name
Relationship to Participant: *
Reference's Phone Number *
Please enter a valid phone number.
Reference's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Emergency Contact Information

Provide contact information in the event of an emergency at camp.
Emergency Contact Name *

First Name Last Name
Relationship to Participant *
Home Phone Number *
Please enter a valid phone number.
Cell Phone Number *
Please enter a valid phone number.
Emergency Contact Primary Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Insurance Information

Provide participant's insurance information.
Participant has insurance: *

Yes No
Insurance Company
Name of Policy Holder
Insurance Company Phone Number
Please enter a valid phone number.
Policy Number
Group Number
GHPP Number
MediCal Number

Certifications | Trainings Completed

Please provide any relevant certifications.
Participant is CPR Certified: *

Yes No
Date of Certification

Month Day Year
Date
Participant is First Aid Certified: *

Yes No
Date of Certification

Month Day Year
Date
Participant has Wilderness First Aid training: *

Yes No
Date of Certification

Month Day Year
Date
Participant is a Life Guard: *

Yes No
Expiration Date

Month Day Year
Date
Certificate Number
Medical Staff ONLY
Type of Licensed Medical Professional
License Number
State where Licensed
License Expiration Date

Month Day Year
Date
Copy of Medical License

Cancel of

Healthcare Provider Information

Provide participant's healthcare provider.
Primary Care Physician
Primary Care Physician's Name *

First Name Last Name
Primary Care Physician's Phone Number *
Please enter a valid phone number.
Date of Last Physical *

Hematologist | HTC Provider

Provide hematologist information for participant's diagnosed with a bleeding disorder, if applicable.
Hematologist | Hemophilia Treatment Center (HTC)
Participant is seen by a Hematologist: *
Hemophilia Treatment Center (choose one):
Hematologist's Name

First Name Last Name
Hematologist’s Phone Number
Please enter a valid phone number.
Date of Last HTC Visit

Medical History

Provide participant's medical history.
Bleeding Disorder Diagnosis
Factor Deficiency (choose one): *
Severity:
Do you have an inhibitor?

Yes No
Are you on prophylaxis?

Yes No

Please indicate infusion dosage schedule for camp:

	Friday	Saturday	Sunday	Monday	Tuesday
Dosage (units)

Participant Form Uploads

Upload the required documents listed below.
Participant's Insurance Card *

Provide photo of front and back of card.
Cancel of
Participant's COVID-19 Vaccination Record *

Cancel of
Participant's Immunization Record

Cancel of

Photography Consent

To be signed by participant.
Permission to Take Photographs

I hereby give consent for photographs and/or motion pictures of myself to be used for any of the following purposes: HASDC publicity, public service announcements on television or the internet, publicity with supporting agencies, scholarship awards, camp promotion or any other agency-approved and supported activity.
Participant’s Signature *

Clear

Camp Firefly Rules

To be read and signed by participant.
Please be sure that you know and agree to the following camp rules before coming to camp. All campers and staff must abide by camp rules for the duration of the camping week. Campers and staff not following camp rules may be asked to leave camp and transportation must be provided by parent/primary guardian.

GENERAL
- Do not bring food, candy or drinks with you. If found, items will be confiscated.
- Electronic equipment of any kind are prohibited at camp.
- Wear shoes at all times. NO SANDALS OR OPEN TOED SHOES AT CAMP!
- No weapons (knives, guns, sling-shots, other weapons, etc.) are ever allowed at camp at any time.
- A staff person must accompany you at all times.
- Follow the buddy system – you should ALWAYS have a buddy with you.
- You must stay on the campgrounds at all times. Leaving is not permitted.
- No visitors are allowed at any time.
- Abide by all YMCA Camp Oakes rules.
TENT RULES
- Stay with your assigned cabin group. Entering other cabins is not permitted.
- Respect the space and property of others – stay out of other campers’ belongings.
- Graffiti (carved or written) is vandalism. We (you) will pay for all damages to camp property.
RESPECT
- Observe the A. D. S. rules at camp – NO Alcohol, NO Drugs, NO Sex at Camp. EVER.
- This is a non-smoking camp. No smoking is allowed anywhere on camp grounds.
- Please treat all campers and staff with respect. Teasing, swearing, inappropriate jokes and rude behavior are unacceptable - inappropriate behavior will result in contacting camper’s parent/primary guardian.
ENVIRONMENT
- Preserve the environment – throw away your garbage and recycle when possible.
- Be kind to animals – they live here, we are only visiting.
- Trees are living creatures too – please respect them by not climbing or pulling out their leaves.
Participant's Signature *

Clear

Camp Firefly Agreements

Signing below indicates you have read and agree to comply with the following summer camp procedures. I understand I will be asked to leave camp if I do not honor my agreement.
Confidentiality Agreement

I will respect the confidentiality of the participants and will not use any access I may have to their names, addresses, telephone, e-mail, etc. for personal gain now or at any time in the future.
Signature *

Clear
Camp Procedures & Guidelines

The Executive Director of the Hemophilia Association of San Diego County shall appoint Camp Directors at his/her discretion, who will be responsible for all staff, personnel and volunteers while at camp.
- Applicants understand that space is limited and therefore not everyone will be chosen.
- All camp volunteers and personnel will be chosen and approved by HASDC staff.
- All volunteers must pass a background check, an interview and provide two individual references.
- If there is any dispute at the camp, it shall be resolved at the discretion of the Camp Director(s).
- There will be one person appointed as Chief Medical Staff In-Charge at all times during the camp week.
- There will be no pictures taken by camp volunteers/staff. HASDC will take care of photography and post all photos on HASDC's social media platforms.
- Camp staff are NOT allowed to friend campers on social media. If this occurs, it can affect your attendance in the future.
- The use of Camp Dragonfly materials including but not limited to camp logo, photographs, articles from its newsletter(s), event fliers, and it's website – are expressly prohibited without advance written approval (electronic mail and faxes are acceptable) from the HASDC Executive Director.
- Any person or persons who refuse to abide by the guidelines set forth (including rules, regulations, procedures, mission, philosophy, etc.) will be asked to leave the Camp.
Signature *

Clear

Release of Liability

To be signed by participant.
I, First Name Last Name , am the participant (over 21-years of age) who will travel to and attend Camp Firefly (hereinafter the "Camp"), at YMCA Camp Oakes, sponsored by the Hemophilia Association of San Diego County ("HASDC"). I understand that the activities involved in Camp will pose the risk of harm or injury. On my own behalf, I hereby freely and expressly consent to release, discharge, indemnify and hold harmless the Hemophilia Association of San Diego County, and their respective agents, employees, and representatives from any damage, claims, loss, or injury sustained by me while traveling to or from the Camp, while attending or participating in any activities at Camp, or any other trips or activities sponsored by the Hemophilia Association of San Diego County. This release includes within its scope any damage, loss or injury sustained as a result of any ordinary negligence, whether active or passive on the part of the Hemophilia Association of San Diego County, or any of their respective agents, employees or representatives.

As the participant, I hereby give my consent to any medical treatment, including any examination, X-ray, anesthetic, medical or surgical diagnosis or treatment, or hospital care to be rendered to me under the general or special provisions of the Medical Practice Act, or to consent to any dental treatment, including any examination, X-ray, anesthetic, dental or surgical diagnosis or treatment, or hospital care to be rendered to me by a dentist licensed under the provisions of the Dental Practice Act. This authorization shall be effective while I am en-route to or from Camp, or involved or participating in any program or activity of Camp, or under the supervision of any personnel associated with the Camp, regardless of the location where treatment or care is rendered, unless earlier revoked by me in writing and delivered to the Hemophilia Association of San Diego County.

The foregoing release is to be construed in accordance with the laws of the State of California. It is intended to release claims, which are not yet known. Accordingly, I hereby waive, on my own behalf, and on behalf of my child/ward, the provisions of California Civil Code §1542, which provides:

“A general release does not extend to claims which the creditor does not know or suspect to exist in his favor at the time of executing the release, which if known by him must have materially affected his settlement with the debtor.”

I have read and understood this Release and Authorization and the information I have given is true and correct.
Participant’s Signature *

Clear
Today’s Date *

Month Day Year
Date
Should be Empty:

2022 Camp Firefly

Staff Self-Assessment

Participant Information

Employment History

Volunteer | Childcare Experience

References

Reference #1

Reference #2

Emergency Contact Information

Insurance Information

Certifications | Trainings Completed

Medical Staff ONLY

Healthcare Provider Information

Primary Care Physician

Hematologist | HTC Provider

Hematologist | Hemophilia Treatment Center (HTC)

Medical History

Bleeding Disorder Diagnosis

Medical Information

Immunizations

Allergies

Psychosocial

Other Medical Conditions

Additional Questions

Medication Information

Participant Form Uploads

Photography Consent

Permission to Take Photographs

Camp Firefly Rules

GENERAL

TENT RULES

RESPECT

ENVIRONMENT

Camp Firefly Agreements

Confidentiality Agreement

Camp Procedures & Guidelines

Release of Liability

	Medication Name	Dose	Fri	Sat	Sun	Mon	Tue	As Needed
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