Camp Kidney 2022 Camper Registration

Camp Kidney 2022 Volunteer Application
WELCOME TO CAMP KIDNEY 2022

Camp Kidney will be held from Friday, October 28th through Sunday, October 30th at Camp Pinerock in Prescott, Arizona. Volunteers must be available/must commit to the entire weekend.

Please see enclosed the 2022 Camp Kidney Volunteer Application. You must submit the enclosed application by Monday, October 3, 2022. Late applications will not be accepted.

Thank you for giving of your time and for being a part of the magic of Camp Kidney.
Pre-Camp Meeting:

Saturday, October 15 (10am to 2pm)

10am - Campers & Families

12pm - Staff/Volunteers/Med Team

BD Headquarters - 850 W Rio Salado Parkway, Tempe, AZ 85281

After the camper meeting, we will be meeting as a team for a more indepth discussion of the schedule/activities of camp as well as any camper notes from our Med Team. Lunch will be provided.

We look forward to seeing you to Camp Kidney 2022!
Volunteer Name:*

First NameLast Name
Birth Date:*

MonthDayYear
Gender*

FemaleMale
Mobile Phone Number:*

Area CodePhone Number
Secondary Mobile Number:

Area CodePhone Number
Email Address:*
Emergency Contact:*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Primary Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Secondary Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Upload Copy of Driver's License

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Medical Insurance Company
Policy Number
Upload Insurance Card Photo

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Select Camp Sweatshirt size:*

SmallMediumLargeExtra-LargeXXL
What type of Camp role are you interested in?*

CounselorProgramming TeamMed TeamAdmin Team
Are you a returning Camp Kidney Volunteer?

YesNo
MEDICATION

For the safety of our campers, we ask that all volunteers provide information regarding their own medications and medical supplies. We also ask that all medications/supplies are kept out of access of all campers. Medications/supplies may be held with Med Team if preferred.

Medication Listing

	Medication Name	How much do you give with each dose? (ml or # of pills)	What time do you give the medication?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

Please list any medications not listed above.
Medical Questions
Allergies*

NONEMedicationsFoodsInsect/Bee StingsLiquids/Drinks and Food
If yes, please provide details:
Please provide information regarding symptoms and treatment for known allergies.
CPR Certified

YesNo
If yes, please include date of certification.
Current Background Check? All volunteers must have a clean background check. Please contact NKFAZ if you do not have a current check.

YesNo
If Yes, please upload :

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Medical Supplies
List ANY & ALL supplies (e.g.; inhaler, epipen etc) you will need/could need at camp- enough for 3 days and 2 nights.

Supplies List

	Supply	Used For	Special Instructions
1
2
3
4
5
6
6
7
8
9
10

IMPORTANT:

Please know that YOU will be responsible to provide all medical equipment, medications and supplies for camp. Be sure to pack enough of everything to last 3 days and 2 nights at camp.
Please include any other medical information you feel the Med Team should be aware of.
Immunizations

.
**For the safety of our campers, all volunteers must have completed the following immunizations prior to being at camp. Please see the complete list below. If there are any concerns, please call NKF AZ.
- Proof of negative TB (2 step or negative TB titer)
  1. One negative TB Test that is within 30 days of volunteering at Camp and one within one year of camp date OR
  2. One negative TB Titer lab draw within one year of camp date
- If history of testing positive for TB – copy of negative chest x-ray and current TB questionnaire complete
- 2 MMR immunizations or POSITIVE (lab draw) titer
- 2 Varicella immunizations or POSITIVE (lab draw) titer
- Tdap immunization – Proof of one in lifetime or exemption signed by medical provider
- Current Flu (Influenza) shot – October through April
- COVID19 Vaccination (must be compliant of CDC requirements including boosters at least 2 weeks (by 10/15/22) before Camp Kidney
** All of the above are valid if you worked at Camp 2019 EXCEPT the flu shot & COVID19 vaccine ** These two must be new in 2022**
Please upload any immunization documents

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Conditions of Volunteering at Camp Kidney
1. Camp Kidney accepts no responsibility for the loss, damage, or theft of my property.

2. I understand that I will be covered solely by the medical insurance policy in which I am enrolled.

3. I authorize a licensed professional to dispense any medications recommended or prescribed by a physician during Camp Kidney.

4. I assume full responsibility for my safety. I agree to release and indemnify Camp Kidney, National Kidney Foundation of Arizona and all of their agents, representatives and employees (paid and volunteer) from any claims, costs, expenses and/or damages which I may sustain or incur.

5. If I behaviors that are harmful to the camp community, I will be sent home. If I am asked to leave camp, it will be at my own expense. I acknowledge that I will be held financially responsible for acts of vandalism caused at Camp Kidney.

6. I agree to hold the professional staff of Camp Kidney, National Kidney Foundation of Arizona and all of their agents, representatives, employees and volunteers free from any liability which may arise from any accident or illness at Camp Kidney.
All of the above information is correct to the best of my knowledge.
Printed Name *

First NameLast Name
Signature*

Clear
Today's Date

MonthDayYear
Date
Emergency Medical Treatment
In the unfortunate case of medical and/or surgical emergencies, I authorize National Kidney Foundation of Arizona’s medical volunteers to render or arrange for the person named below to receive any x-rays, anesthetic, medical, dental, surgical procedure, treatment or medical care which is deemed advisable by and is to be rendered under the supervision of any physician, dentist, or surgeon licensed in the state of Arizona.
Printed Name *

First NameLast Name
Signature*

Clear
Today's Date

MonthDayYear
Date
Media Consent
I give permission to Camp Kidney, National Kidney Foundation of Arizona, Camp Pinerock, and other media invited to camp by Camp Kidney/National Kidney Foundation of Arizona to take and release video footage and photography of the person named below during his/her time at Camp Kidney.

I understand that any video or photo may be used on television, in newspapers, magazines, internet, or in any other medium that National Kidney Foundation of Arizona and Camp Pinerock may choose.
Printed Name *

First NameLast Name
Signature*

Clear
Today's Date

MonthDayYear
Date
Alcohol, Tobacco & Drug Policy
National Kidney Foundation of Arizona and Camp Pinerock Policy forbid the possession or use of any alcohol, tobacco, and/or un-prescribed drugs any time while at Camp Kidney.

Campers who don’t fully comply with this policy will be sent home immediately. In this instance, an authorized parent/guardian will be contacted and required to drive to Camp Kidney in Prescott, Arizona to pick up the camper. Staff and volunteers who don’t comply will also be sent home. No exceptions will be made.

Your signature below indicates your commitment to abide by this policy in its entirety. Please contact the National Kidney Foundation of Arizona at (602)840-1644 if you have any questions regarding this policy.
Printed Name *

First NameLast Name
Signature *

Clear
Today's Date

MonthDayYear
Date

Thank you for volunteering at Camp Kidney.

We can't wait to see you in October.

Ashleigh & Jen

*If you were unable to upload any of the required documenations, please email them directly to ashleighs@azkidney.org*
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Camp Kidney 2022 Volunteer Application

MEDICATION

Medical Questions

Medical Supplies

Immunizations

Conditions of Volunteering at Camp Kidney

Emergency Medical Treatment

Media Consent

Alcohol, Tobacco & Drug Policy