2025 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. Once you have received your confirmation email, confirming your acceptance as a counselor for Kiwanis Camp Casey, you will receive information about the three counselor training sessions, scheduled the three Monday evenings before camp. While we prefer you can attend all three sessions, please communicate any conflicts to your Head Counselors so they can make alternative arrangements for your training. 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 27th, 2025?* 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. 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. Once you have received your confirmation email, confirming your acceptance as a counselor for Kiwanis Camp Casey, you will receive information about the three counselor training sessions, scheduled the three Monday evenings before camp. While we prefer you can attend all three sessions, please communicate any conflicts to your Head Counselors so they can make alternative arrangements for your training. 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.Contact InformationName* First Last Date of Birth* MM slash DD slash YYYY Pronouns* he/him she/her they/them other (enter below) Please enter your pronouns:Please use the form :subject/object/possessive: (e.g. they/them/theirs)Do you prefer to room among feminine-presenting or masculine-presenting peers? Feminine-presenting Masculine-presenting Have you volunteered for Kiwanis Camp Casey Before?* Yes No How did you hear about camp?*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.Permanent 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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Phone (cell)*Phone (home)Is your current address different than the permanent address you already listed?* Yes No Current 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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin 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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin 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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin 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.*What role do you take when working on a team? What is your greatest strength when working with others?*What previous experience do you have working with children?*What is one camp activity you would plan?*Please give details about how you would execute it and how you would make it accessible for all campersWhy do you want to volunteer for Camp Casey?*Are you able to attend the Casey picnic on Saturday, May 10th at Miller Community Center from 11am to 1pm? Yes No Camp ActivitiesPlease indicate the areas you have experience with:**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.*Activity Groups – First Choice*Please do not select the same choice multiple times!Little Kid Night or Big Kid NightScience & NatureArts & CraftsCookingCarnivalGame ShowTalent ShowDanceGraduationContenderActivity Groups – Second Choice*Please do not select the same choice multiple times!Little Kid Night or Big Kid NightScience & NatureArts & CraftsCookingCarnivalGame ShowTalent ShowDanceGraduationContenderActivity Groups – Third Choice*Please do not select the same choice multiple times!Little Kid Night or Big Kid NightScience & NatureArts & CraftsCookingCarnivalGame ShowTalent ShowDanceGraduationContenderPlease 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. X-Small Small Medium Large X-Large XX-Large XXX-Large Health Information* 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?Will you be fully vaccinated for COVID-19 by July 27, 2025?* Yes No Fully vaccinated means at least two weeks out from your second immunization shot and you have the most recent booster dose recommended for you.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 read Camp Casey Counselor Volunteer Release Form.* I have reviewed the Volunteer Release Form. I know what is expected and agree to the guidelines specified.
