Fillable 2019 Counselor Application WRITABLE EXT FEATURES (Southeast Missouri State University)

Fill Online, Printable, Fillable, Blank 2019 Counselor Application WRITABLE EXT FEATURES (Southeast Missouri State University) Form

Use Fill to complete blank online SOUTHEAST MISSOURI STATE UNIVERSITY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

2019 Counselor Application WRITABLE EXT FEATURES (Southeast Missouri State University)

On average this form takes 48 minutes to complete

The 2019 Counselor Application WRITABLE EXT FEATURES (Southeast Missouri State University) form is 8 pages long and contains:

  • 0 signatures
  • 109 check-boxes
  • 140 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Southeast Missouri State University

BROWSE SOUTHEAST MISSOURI STATE UNIVERSITY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
1
ATTACH
YOUR PHOTO
HERE
For office use
Date received: ________________________
Notified: _____________________________
Excel: ________________________________
Application: __________________________
Release forms (5): _____________________
Confidentiality: ________________________
CWB waiver: _________________________
Background check: _____________________
References: _________ ________ ________
SOR: ________________________________
In SF/SF update: __________ / ___________
Interview: ____________________________
Accepted/not accepted date: ___________
Accepted/not accepted initials: __________
Annie’s Hope
presents
Camp Courage and Camp Courage – Teens
… in the Chocolate Factory!
Camp Courage: Saturday, June 1 – Friday, June 7, 2019
Camp Courage – Teens, Saturday, June 8 – Friday, June 14, 2019
Priority deadline: Friday, April 5, 2019
Late deadline: Tuesday, April 30, 2019
All applicants who have not previously volunteered at Camp with Annie’s Hope must complete an interview with an Annie’s Hope
staff member. Interviews must be completed by Friday, May 17
th
, 2019.
Volunteer Application
Thank you for widening the circle of support for grieving kids.
If you have previously volunteered at Camp, please complete sections with “*” and all agreements, releases, and waivers.
*Name: _________________________________________________________________ *Date of birth: _______________________
*Gender: Female Male Choose to not identify *Age: ______________________________
*I prefer the pronouns: She/her/hers He/him/his They/their/theirs Ze/hir/hir
*Preferred name (if different from above): ________________________________________________________________________
*Home address: ___________________________________________ *City, State, Zip: ____________________________________
*Home phone: ____________________________________________ *Cell phone: _______________________________________
*Email address: _______________________________________________________________________________________________
*School/other address: _____________________________________ *City, State, Zip: ____________________________________
*Driver’s license number & State: _____________________________ *Social Security Number: _____________________________
*Employer (if applicable): ____________________________________ *Supervisor’s name: _________________________________
*Employer address: _________________________________________ *City, State, Zip: ____________________________________
*May we call you at work? Yes No *Work phone: _____________________________________
*To which camp are you applying? Both Camp Courage Camp Courage – Teens
*Do you have any conflicts with the dates whereby you would like to leave camp? Yes No
*If yes, when and why? _________________________________________________________________________________________
*Have you previously volunteered at Camp Courage or Camp Courage – Teens (FKA Camp Erin – St. Louis)?
Yes No
*If yes, in what capacity and what years?
Arts & Crafts Coordinator Arts & Crafts Helper Cabin Counselor Camp Nurse Helping Hand
’00 – ’12 ’12 ’13 ’14 ’15 ’16CC ‘16CE ‘17CC ‘17CE ‘18CC ‘18CE
How did you learn about Annie’s Hope and Camp Courage/Camp Courage – Teens?
Please explain why you would like to volunteer for Camp Courage/Camp Courage – Teens.
2
What do you hope to gain from volunteering for Camp Courage/Camp Courage – Teens?
What talents, experiences, skills, knowledge, etc. can you offer to the kids of Camp Courage/Camp Courage – Teens?
*In what way would you like to volunteer for Camp Courage/Camp Courage – Teens? Please check your areas of interest.
Arts & Crafts Coordinator Arts & Crafts Helper Cabin Counselor Camp Nurse Helping Hand
*If you desire to be a Cabin Counselor, what age and gender of campers would you prefer? Please choose a first and second
preference. Female Male
*Camp Courage: 6 – 7 year-olds 8 – 9 year-olds 10 – 12 year-olds
*Camp Courage – Teens: 12 – 13 year-olds 14 – 15 year-olds 16 – 18 year-olds
*Do you have skills in any of the following areas? Archery Canoeing Certified lifeguard
Claywork Dancing Drama Drawing/painting Fishing Musical instruments
Nature/hiking Orienteering Photography Rock climbing Ropes course certification
Singing Sports
*What is your preferred t-shirt size? Please select one.
Small Medium Large XL 2XL 3XL
The children, teens, and adults Annie’s Hope serves depend on us to recruit reliable, safe, and committed
volunteers. With that in mind, we need to ask a few tough questions. Please answer the questions honestly
and completely. All answers are strictly confidential.
Grief and loss can occur in a variety of ways, including; death, divorce, moving, job and career changes, remarriage, disease, etc.
Please describe any losses you have experienced. Include when the loss occurred, its impact on your life, how you have coped,
and how you believe the experience will enhance or impede your ability to volunteer for Camp Courage/Camp Courage – Teens.
If more space is needed, please use the blank page at the end of this form. *Returning volunteers, please include any losses you
have experienced since your last volunteer commitment with Annie’s Hope.
3
Camp Courage/Camp Courage – Teens volunteers share a wealth of experiences and talents. Pease share yours.
Education:
High school: ______________________________________________________ Graduation date: ____________________________
College: __________________________________________________________ (Anticipated) Graduation date: _________________
Degree studied/completed: _____________________________________________________________________________________
Work history:
(Please share details of your work history from the past five years, starting with the most recent)
Employer: ___________________________________ Job title: _____________________ Dates: ______________________________
Supervisor: __________________________________ Phone number: ____________________________________________________
Employer: ___________________________________ Job title: _____________________ Dates: ______________________________
Supervisor: __________________________________ Phone number: ____________________________________________________
Employer: ___________________________________ Job title: _____________________ Dates: ______________________________
Supervisor: __________________________________ Phone number: ____________________________________________________
Employer: ___________________________________ Job title: _____________________ Dates: ______________________________
Supervisor: __________________________________ Phone number: ____________________________________________________
Volunteer experience:
(Please share any prior volunteer experience you have had interacting with children and adolescents. Include other camps, agencies or organizations, such as Big
Brothers Big Sisters, Sunday School, Scouting, Little League, etc.)
Organization/Group: _______________________________________ City/State: ___________________ Dates: ________________
Contact: __________________________________________________ Phone: ____________________________________________
Organization/Group: _______________________________________ City/State: ___________________ Dates: ________________
Contact: __________________________________________________ Phone: ____________________________________________
Organization/Group: _______________________________________ City/State: ___________________ Dates: ________________
Contact: __________________________________________________ Phone: ____________________________________________
Organization/Group: _______________________________________ City/State: ___________________ Dates: ________________
Contact: __________________________________________________ Phone: ____________________________________________
Please list three references (not relatives) you have known for at least a year:
Name: ____________________________________________ Relationship: ________________ Length of relationship: __________
Email: _____________________________________________ Phone: ___________________________________________________
Name: ____________________________________________ Relationship: ________________ Length of relationship: __________
Email: _____________________________________________ Phone: ___________________________________________________
Name: ____________________________________________ Relationship: ________________ Length of relationship: __________
Email: _____________________________________________ Phone: ___________________________________________________
*Emergency contact:
Name: ____________________________________________ Relationship: ________________ Phone: _______________________
4
*What is important for Annie’s Hope to know about your spiritual, emotional, dietary, medical, or physical needs so we may help
you be successful at Camp Courage/Camp Courage – Teens? Please include if you eat gluten free, lactose free, vegan, or
vegetarian meals.
Due to the nature of our work with children and adolescents, volunteers who have had any child/minor related criminal charges
filed against them are automatically excluded from volunteering in parts of our organization that would require direct contact
with children and/or teens. Annie’s Hope will complete background and sex offender registry screenings for every volunteer who
applies to work with children or teens.
Have you ever been convicted of a crime? Yes No
If yes, please explain:
Please list your places of residence for the past ten years.
Address: _________________________________________________ City, State, Zip: ______________________________________
County: __________________________________________________ Dates: _____________________________________________
Address: _________________________________________________ City, State, Zip: ______________________________________
County: __________________________________________________ Dates: _____________________________________________
Address: _________________________________________________ City, State, Zip: ______________________________________
County: __________________________________________________ Dates: _____________________________________________
Has your name changed? Yes No
If yes, what other names have you gone by? ________________________________________________________________________
To raise money for our programs, Annie’s Hope applies for grant funding from foundations and corporations.
To submit successful grant applications, we need answers to the following questions.
Please remember your answers are strictly confidential and optional.
*Do you identify with an organized religion? Yes No
*If yes, please state the religion: _________________________________________________________________________________
*What is your identity? Check as many as applicable:
African American or Black Asian Biracial Caucasian Hispanic or Latino
Native American Indian
Other: _______________________________________________________________________________________________
*Are you now (or previously) a member of the Armed Services? Yes No
*If yes, how were you involved? Active Reserves Veteran National Guard
*If yes, which military branch(es) are/were you a member of?
Air Force Army Coast Guard Marines Navy ROTC
5
Sponsor One:
Sponsor One is an optional, simple, and online fundraising challenge for Camp Courage/Camp Courage – Teens volunteers.
Participating volunteers are tasked with the goal of raising $925 – the financial value of one campership to Camp Courage/Camp
Courage – Teens. Since 2015, Camp volunteers participating in Sponsor One have raised over $50,000 for the free grief support
programs offered by Annie’s Hope.
Would you like more information about how to participate in Sponsor One? Yes No
(Participation in this fundraising effort DOES NOT impact our selection of volunteers and is NOT mandatory, although ANY contribution raised or effort made is
greatly appreciated.)
*On the final page of this application, there are four options of how to obtain a background check. Please indicate which method
you have chosen:
Previously registered with Missouri Department of Health and Senior Services. (Due to time constraints, please call 1 (866)
422-6872 to request a current background check for yourself. Ask the DHSS employee for the request number. When you
receive a copy of the background check in the mail, please make a copy and email/mail/fax to Annie’s Hope).
Will register with Missouri Department of Health and Senior Services (ONLY FOR MISSOURI RESIDENTS). (Due to time
constraints, after you register, please call 1(866) 422-6872 to request a current background check for yourself. When you
receive it, please make a copy and email/mail/fax to Annie’s Hope).
Missouri Automated Criminal History Site and it is attached (ONLY FOR MISSOURI RESIDENTS)
St. Louis Police Department (ONLY FOR ST. LOUIS COUNTY RESIDENTS)
Public Records Search
I already have one that was obtained since June 15
th
, 2018 and the copy is attached.
The undersigned acknowledges and agrees that (1) he/she is not required, if called upon, to perform the volunteer service herein
applied for and that Annie’s Hope is not required to assign, or actively seek to assign, him/her as a volunteer even after appropriate
training; and, (2) as a part of the Agency’s assessment process, additional information will be elicited from the applicant by Agency
personnel.
I affirm under the penalties of perjury that all the information supplied to Annie’s Hope during the application process is true and
accurate.
Printed name of applicant: _________________________________________________ Date: _______________________________
Signature of applicant: __________________________________________________________________________________________
If you are under the age of 18, a parent or guardian must provide permission for you to
volunteer at Camp Courage/Camp Courage – Teens.
I, ___________________________________, give permission for my child, ___________________________________, to volunteer
at Camp Courage/Camp Courage – Teens.
Printed name of parent/guardian: ___________________________________________ Date: _______________________________
Signature of parent/guardian: ___________________________________________________________________________________
Please submit completed applications by mail, email or fax to:
Annie’s Hope – The Center for Grieving Kids
Mailing address: 1333 W. Lockwood, Suite 104 • Glendale, MO 63122
Email: applications@annieshope.org
Fax: (314) 918-1438
For questions or concerns, please contact Annie’s Hope at (314) 965-5015.
6
Annie’s Hope & Camp Courage/Camp Courage - Teens
Please read the information below. Sign your name under each of the five releases/agreements if you
understand and fully agree to follow all aspects of the regulations and guidelines outlined.
PHOTOGRAPHIC RELEASE
I, ________________________________________, hereby authorize Annie’s Hope to take photographs, film, audiotapes,
and videotapes of me and my art work and to use them in newspapers, publications, and presentations. Annie’s Hope may use
these such items and information in whatever way Annie’s Hope considers proper and desirable.
Signature: _______________________________________________________________ Date: _______________________________
RELEASE OF RESPONSIBILITY FOR VALUABLES
I, ________________________________________, hereby release Annie’s Hope & Camp Courage/Camp Courage - Teens
staff and volunteers of any responsibility for valuables that I choose to bring to Camp Courage/Camp Courage – Teens. I
acknowledge that Camp Courage/Camp Courage – Teens guidelines encourage all valuables to be left at home.
Signature: _______________________________________________________________ Date: _______________________________
SOCIAL MEDIA AGREEMENT
I, ________________________________________, understand that, due to a commitment to maintain confidentiality,
Annie’s Hope prohibits me from sharing any of the pictures I take – electronically or in print – at Camp Courage/Camp Courage -
Teens pre-camp party and at Camp Courage/Camp Courage - Teens itself with others or on any public social media forum.
Signature: _______________________________________________________________ Date: _______________________________
RELATIONSHIP WITH CAMPERS AGREEMENT
I, ________________________________________, understand that, due to liability concerns, Annie’s Hope prohibits me
from any and all forms of contact with a camper of Camp Courage/Camp Courage - Teens outside of the camp setting or other
Annie’s Hope activities.
Signature: _______________________________________________________________ Date: _______________________________
SUBSTANCE USE AGREEMENT
I, ________________________________________, understand that consumption or possession of alcohol, cigarettes,
prescription narcotics, marijuana or any illegal substance/drug while training or volunteering at Camp Courage/Camp Courage -
Teens is strictly prohibited. I understand that all volunteers must abstain from using any substances or consuming alcohol for a
minimum of 8 hours before arriving to training. I understand that a breach of this agreement may warrant immediate dismissal.
Signature: _______________________________________________________________ Date: _______________________________
7
Confidentiality Agreement
Children, teens and families who come to programming offered by Annie’s Hope are extremely vulnerable and in
the midst of beginning again after a death has rocked their very existence.
As Camp Courage/Camp Courage – Teens volunteers and staff, you become a piece of the healing process for the
children, teens, and families. They open their hearts and souls in the hopes that they will one day find peace.
Often what they share is highly personal and private. They may not have expressed the information with anyone
else - not even with family, friends or relatives. They share with us because they want and need to. They trust that
their stories will be protected and respected.
It is a privilege to hear the pain of another. With that privilege comes much responsibility. You are to hold their
stories in a sacred trust. All information shared by children, teens, families, and other facilitators is strictly
confidential. Outside Annie’s Hope programs, it is not to be discussed - even to our own families and friends.
There are five exceptions to preserving confidentiality. They are:
1. Any indication of suicidal ideation (suicidal thoughts).
2. Any indication of physical, mental, or sexual abuse or neglect.
3. If there is any reason to be concerned about drug and alcohol use/abuse by a child or teen, we reserve the
right to inform the parent/guardian.
4. If there is information ordered by the court including a subpoena. We will attempt to contact the party
named about this order. If the release of information is opposed, a court may nevertheless require
compliance with the order.
5. If we learn that someone participating at Annie’s Hope might commit an act of violence. In this case, we
may take steps to protect the intended victim against such danger, inform the police, or both.
Volunteers who suspect that a person may harm him/herself, another, or property, or that other conditions exist in
a family that are beyond the scope of our services, are to, with the child’s, teen’s or adult’s knowledge, inform the
Camp Director immediately. The Camp Director will assess the severity of the issue and refer to emergency
services as needed.
Signature: ____________________________________________________ Date: __________________________
8
Revised 9/2017
HIGH ROPES WAIVER
MEDICAL STATEMENT
I recognize that challenge course activities can be a strenuous endeavor requiring me to be in good physical condition. I hereby
certify that I do not suffer from any physical infirmities or illnesses which would affect my ability to engage in the challenge
course activities and that if I am now under the treatment for any of the following, I will check the proper heading and discuss
them with the Camp Wartburg instructor.
I further certify that all regular medication(s) that may affect my ability are listed in the space below and that I have not
consumed any alcoholic beverages or drugs within the last 12 hours.
Check appropriate headings:
Alcoholism
Hearing Loss or Impairment
Orthopedic Problem
Back or Neck Injury
High or Low Blood Pressure
Pregnancy
Cardiac or Pulmonary Condition or
Disease
Insect Allergies
Recent Injuries
Diabetes
Kidney Related Disease
Shortness of Breath
Drug Addiction or Dependency
Mental Distress
Other
Fainting Spells or Convulsions
Nervous Disorder
Please list any medications that may affect your ability to participate below:
Medication:
Dosage:
Medication:
Dosage:
AKNOWLEDGEMENT OF RISK AND ASSUMPTION OF PERSONAL RESPONSIBILITY
I understand that during my participation in this adventure course or activity that I may be exposed to psychologically and physically
stressful and challenging situations.
I understand, too, that although the program has taken precautions to provide organization, supervision, instruction, and equipment
for each activity, it is impossible for the program to guarantee absolute safety. Also, I understand that I share responsibility for
safety and I assume that responsibility. Further, I waive any claim that may arise against Camp Wartburg and/or Camp Wartburg’s
employees as a result of my participation in the program, except those which are the direct result of the gross negligence of Camp
Wartburg, its affiliate, or their employees.
I have accepted responsibility for verifying my personal health and my medical history above and certify that I have no physical or
psychological problems that would prohibit my participation in this program.
I further agree to comply with all instructions and directions of Camp Wartburg staff during my participation.
I (we) agree with the above stated terms and acknowledge that there can be no guarantee of safety against risk and unforeseen
accident, as detailed above, and consent to the participation of the above named participant in the adventure program. In case of
emergency, I understand that every effort will be made to contact parents or guardians of participants. In the event that I/they
cannot be reached, I hereby give permission to the physician selected by the Camp Director to hospitalize, secure proper treatment
for, and to order injection, anesthesia, or surgery for my child, as named herein.
Camp Wartburg reserves the right to ban a participant from taking part in the activity due to their inability to follow safety
guidelines (without refund). All participants must wear close-toed shoes. Failure to do so will result in inability to participate.
Printed Name of Participant
Signature of Participant
Date
Printed Name of Parent/Guardian
Signature of Parent/Guardian (If participant is under 18)
Date
Revised 2/8/2019 9
Please keep this page for your reference.
All Camp Courage/Camp Courage – Teens volunteers, new or returning,
must have a background check completed annually.
Option 1 (preferred): This is only for Missouri residents. Register with the Missouri Department of Health and Senior Services as
shown below. A week after registration, call 1-866-422-6872 to request a current background check. It can be done immediately.
Ask the DHSS employee for the request number. You will receive a copy of the background check in the mail. Please copy it and
email/mail/fax to Annie’s Hope immediately.
Go to website http://health.mo.gov/safety/fcsr/. Read the details and then click on “Register Online.” You may also register by
submitting the Worker Registration Form, completing the form, providing a copy of your social security card and sending a one time
$13.00 registration fee to:
Missouri Department of Health and Senior Services
Fee Receipts Unit
P.O. Box 570
Jefferson City, MO 65102
Option 2: This is only for Missouri residents. Register with the Missouri Automated Criminal History Site. Go to
https://www.machs.mshp.dps.mo.gov/MocchWebInterface/home.html to obtain your background check. You will need to set up
an account- simply click on the link “New to this site? Click here to get started” on the right side. Once you have set up your
account, you will need to provide your name, date of birth, or social security number. There is a $13 fee (plus a convenience fee).
The background check will be sent to your account. It will NOT be emailed or mailed to you. You will need to print your background
check and submit it with you camp application.
Option 3: St. Louis County Police Department Bureau of Central Police Records
Arrive in person to the St. Louis County Police Department Bureau of Central Police Records. The address is 7900 Forsyth in Clayton,
MO, Room B-013, on the street level (accessible from either Central, Meramec Avenue, or the Memorial Park Entrance) of the Police
Headquarters. The office is open from 7:30 AM to 5:00 PM, Monday through Friday (excluding holidays). The number is 314-615-
5317. If your main residence is in a different county, please call the police station in your county and ask about their process for
record checks.
Criminal History Record Checks may be obtained by applying in person with the following identification:
1. Drivers License with Social Security Number
2. Drivers License AND Social Security Card (if SSN is not on license)
3. Birth Certificate, original or sealed copy AND Social Security Card AND picture ID
4. Military Identification
5. Immigration and Naturalization ID AND Social Security Card
6. State Identification with Social Security Number
7. State Identification AND Social Security Card, if SSN not on ID
8. Legible Traffic Citations with Social Security Number AND Picture ID
If using more than one type of identification, i.e. Drivers License and Social Security Card, both forms of identification must be in the
same name. A Marriage Certificate/Divorce Decree/Court Documents are required for any legal name change.
Once again, criminal history record checks must be obtained in person by the individual requesting the record check. A record check
cost, for a criminal history record check for incidents that occurred within St. Louis County is $4.50 and a criminal history record
check for incidents that occurred within the City of St. Louis is $4.50. The total cost for a City and County Record Check is $9.00.
Option 4: Whether your residence is in Missouri or not, go to https://www.publicrecords-search.com/servlet/service. Click “order”
by the “State Report” under the Standard Criminal Background Check. There is a $12.95 fee.
Option 5: If you have had a complete background check any time after July 2018, a copy for Annie’s Hope records may be sufficient.
Due to Annie’s Hope & Camp Courage/Camp Courage - Teens budget constraints, we are requesting that Camp Courage/Courage –
Teens volunteer applicants cover the cost of the background check fee. If this is not possible, please do not hesitate to call.
For information or questions contact Annie’s Hope at (314) 965-5015.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

2019 Counselor Application WRITABLE EXT FEATURES (Southeast Missouri State University)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 25 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document