2021 Counselor Application Please completely fill-out this application to assist us in reviewing your Counselor Application. We have limited space available and applications are not accepted until fully completed. After submitting this application, you will be contacted by a Head Counselor who will notify you regarding the status of your application. If you do not hear within two weeks of submitting your application, please contact headcounselors@campcasey.org. If anything regarding the information you provided between now and the start of camp changes, please, ASAP, contact headcounselors@campcasey.org . Last minute counselor cancellations can cause great hardship for the safety and planning for camp. Please understand you are making a commitment that will be life-changing for you and the campers you will be serving.Will you be between the ages of 15 and 26 years old on July 24th, 2021?* Yes No Due to the popularity and accommodations for counselors, we have to limit the number of counselors to those between the ages of 15 and 26 years old at the time of camp.We regret to inform you, based on your age we cannot accept your application as a counselor for Kiwanis Camp Casey. Though a most rewarding experience, Kiwanis Camp Casey demands maturity, is a physically exhausting experience and our campers enjoy interacting with age like peers. However, if you are younger than 16 we do encourage you to volunteer at our May picnic or explore volunteering for Seattle Adaptive Sports or the Crew. Seattle Adaptive Sports or Seattle Adaptive Sports - The Crew Youth Social both experiences will give you wonderful opportunities meeting our Casey campers and better prepare you if you decide to reapply as a counselor when you turn 16 or older. If you are older than 26 years of age we encourage you to consider joining North Central Seattle Kiwanis If you have any questions or concerns please email director@campcasey.org Camp Casey 2021 will be taking place between the hours of 8am and 5pm at Magnuson Park over the week of July 26th to July 30th. Depending on the number of camper applications and our needs, you might not be requested to attend each day of camp. Contact InformationAre you able to transport yourself to and from Camp (Magnuson Park) each day (July 26 -July 30th)?*We are moving to a day camp model for 2021, and overnight accommodations will not be provided. Counselors will be required to show up at 8am and leave about 5pm each day of camp Yes No If you care to elaborate on what you need in terms of accommodations to attend Camp this year, please do so How did you hear about camp?* Have you volunteered for Kiwanis Camp Casey Before?* Yes No How many years have you volunteered as a counselor?* When was the last year you volunteered?* If referenced, what organization/who referred you to Camp Casey? Please specify any prior experience in service clubs. 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SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Parent/Guardian Contact InformationName* First Last Relation Parent/Guardian Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Best Phone:*Alternate Phone:Email Emergency ContactIs your Emergency Contact the same as your Parent/Guardian?* Yes No Name* First Last Relation Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Best Phone:*Alternate Phone:Email Education and Work HistoryName/Location of High School* High School Information*Please indicate last grade completed. 9th Grade 10th Grade 11th Grade 12th Grade Graduation Year* Do you have another educational institution to report such as college or university?* Yes No Name/Location of School* Course of Study/Major* Graduation Year* Type of Degree/Certification* Have you had any work experience?* Yes No Employer Name* Position Title* Start Date* MM slash DD slash YYYY Is this your current employment? Yes No End Date* MM slash DD slash YYYY Duties and Responsibilities*Do you have any experience working with children or adults with special needs?* Yes No Please write about your experience*Describe briefly an experience where you faced a challenge and how you resolved it.*Describe briefly an experience where you had to show leadership qualities.*Describe briefly an experience where you had to use teamwork to succeed.*ReferencesPlease provide two personal references that we may contact to learn a bit more about you (no relatives, please):Reference 1 Name* First Last Reference 1 Phone*Reference 1 Email* Reference 2 Name* First Last Reference 2 Phone*Reference 2 Email* **Leadership** Camp leadership positions include chairing an activity such as the dance, graduation, talent show, game show night, carnival, Olympics, or another fun event you help think of. There are Arts and Crafts leaders, interest group leaders and then of course Unit Leaders, Barracks Captains, and Head Counselors. Are you interested in a leadership position?* Yes No Please describe your leadership interests.*Camp ActivitiesPlease indicate the areas you have experience with:Story Telling* Yes No Arts and Crafts* Yes No Drama/Skits* Yes No Organized Sports* Yes No Music/Play an instrument* Yes No Please describe your musical background, as well as any instruments you play.*Are you available to help with planning camp entertainment activities before camp?* Yes No Please provide any other information you would like to share:Camp Casey T-ShirtsPlease provide us with your t-shirt size so we an provide you a t-shirt. Small Medium Large X-Large XX-Large XXX-Large Health InformationWe will be requiring all counselors and volunteers to be fully vaccinated by the time of Camp. Are you or will you be fully vaccinated before camp?* Yes No Depending on the WA state guidelines at the time of camp, will you be comfortable in a camp setting where masks are not mandatory?* Yes No Do you understand that if you begin to experience symptoms that fall under the category of COVID-19, you will need to be tested and obtain a negative test prior to attending camp?* Yes No * I understand that the Volunteer, Kiwanis Camp Casey Head Nurse is primarily responsible for the medicine and health care plan provision for the campers. All counselors and volunteers must be mature enough to take responsibility for administration of their own personal medications, and must safely keep their personal medications with their own living space. The Head Nurse is responsible for the first aide needs and emergencies of all the camp, and is available to volunteers/ counselors if over the counter (OTC) medications are needed. Therefore, the separate release form must be signed by all counselors and volunteers or parent/guardians in the case of underage counselors, younger than 18. The information provided in the medical history will be kept in a confidential location, available to the Kiwanis Camp Casey Medical trained leader volunteers only, and to the extent any information is designated as protected health information under the Health Instructions ADD/ADHD Details Insurance Portability and Accountability Act (HIPAA), Kiwanis Camp Casey agrees to abide by all applicable laws. Please list all prescription medications you are taking.Do you have a history of any of the following illness or conditions; or are you receiving medications for such illnesses or conditions?ADD/ADHD* Yes No ADD/ADHD Details*Anxiety/Depression* Yes No Anxiety/Depression Details*Asthma* Yes No Asthma Details*Back/Neck Pain* Yes No Back/Neck Pain Details*Diabetes* Yes No Diabetes Details*Eating Disorder* Yes No Eating Disorder Details*Emotional Problems/Self Injurious Behavior* Yes No Emotional Problems/Self Injurious Behavior Details*Headaches* Yes No Headaches Details*Heart Conditions/Problems* Yes No Heart Conditions/Problems*Hepatitis/Hepatitis Exposure* Yes No Hepatitis/Hepatitis Exposure Details*Seizures/Convulsions* Yes No Seizures/Convulsions Details*Auto Immune Condition* Yes No Auto Immune Condition Details*Other* Yes No Other Details*Are you currently being seen (or been seen in the last 3 years) by a psychiatrist, psychologist, therapist or any other related specialist for any acute or chronic mental health condition?* Yes No Please Provide Details*Do you have any medical, mental or emotional conditions which may affect your ability to perform any of the essential functions of a Kiwanis Camp Casey Counselor?* Yes No Please Provide Details*Have you had any recent operations or serious injuries?* Yes No Please Provide Details*Have you been exposed to a communicable disease (e.g. head lice, strep throat, mononucleosis, etc) in the last six (6) months?* Yes No Please Provide Details*Our staff are involved in an active program. Counselors will need to physically assist campers, lift campers, and push wheelchairs used by campers, as well as participate in activities such as dancing, swimming, and running. Do you have any physical, medical, or other type of condition which we need to know about related to these responsibilities?* Yes No Please Provide Details*Dietary*Note: The Camp Casey kitchen staff will do their best to accommodate common food allergies. However, given the complexity and procedures for vegan diets the kitchen staff will not be able to provide vegan meals. Sorry for the inconvenience. Gluten Intolerant Gluten Allergy Lactose Intolerant Vegetarian No Food Restrictions LegalHave you been accused of harassment of any person?*The camp's policy is to prohibit all forms of harassment by our counselors, volunteers and campers. This includes sexual, racial, religious, and other forms of harassment. Yes No Please Explain*A prior accusation is not an automatic bar to volunteer at Kiwanis Camp Casey. The type of conviction and when it occurred will be evaluated by the camp before a decision is made.Have you ever been convicted of a crime, other than a minor traffic offense?* Yes No Please Explain*A prior conviction is not an automatic bar to volunteer. The type of conviction and when it occurred will be evaluated by the camp before a decision is made.Have you had findings made against you in any civil adjudicative proceeding?* Yes No Please Explain*A prior conviction is not an automatic bar to volunteer. The type of conviction and when it occurred will be evaluated by the camp before a decision is made.Background Check*I understand my application is not complete until Background check has been completed by Camp Staff. Pursuant to requirements of RCW 43.43.834 Washington state rules. I authorize investigation of all statements herein and release Kiwanis Camp Casey and all others from liability in connection with same. I understand that untrue, misleading, or omitted information herein may result in dismissal, regardless of the time of discovery by the camp. AcknowledgementPlease read and agree to the forms below.Please read Camp Casey Counselor Volunteer Code of Conduct.* I have reviewed the Counselor Volunteer Code of Conduct. I know what is expected and agree to the guidelines specified. Please note you will be asked to read and sign the Camp Casey Counselor Volunteer Release Form before attending Camp. (Sent on a following date)* I acknowledge that I will be asked to review the Release Form prior to attending camp. Agreement will be mandatory prior to attending camp.
