2025 Nurse Application Please completely fill-out this application to assist us in reviewing your Nurse Application. Applications cannot be accepted until fully completed. After submitting this application, you will be contacted by the Head Nurse who will notify you regarding the status of your application. If anything regarding the information you provided between now and the start of camp changes, please contact [email protected] so we can have the most up-to-date information. Last minute cancellations cause great hardship for camp leadership and places increased risk management concern for our campers. Have you volunteered for Kiwanis Camp Casey Before?* Yes No Are you associated with another Kiwanis Club?* Yes No What other Kiwanis Club are you associated with?*What organization or person, if any, referred you to Camp Casey?Contact InfomationName* First Last Date of Birth* MM slash DD slash YYYY Sex assigned at birth* Male Female Preferred Pronouns* she/her he/him they/them 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 (home)*Phone (work)Phone (cell)Emergency ContactName* 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 Primary Phone*Alternate PhoneEmail In the event of a medical emergency, what information will an EMT or medical personal attending to your care need to know?Nursing InformationAre you a current nursing student?* Yes No What school are you attending?*How many years of nursing experience do you have?*Nursing License information:* Name as Appears on License License/Credential Number State of Licensure Do you have a secondary Nursing License to list?* Yes No Secondary Nursing License information:* Name as Appears on License License/Credential Number State of Licensure Please list certifications you hold, with their expiration dates:*Do you have personal nurse liability insurance?*Personal nurse liability insurance is required to volunteer at camp, we will assist you in signing up and will reimburse you for the cost. Yes No What company do you hold your policy through?*When does this policy expire?* MM slash DD slash YYYY Employment InformationCurrent Employer:*Position/Area of Nursing:*Start Date:* MM slash DD slash YYYY Duties and Responsibilities:*Do you have any experience working with children or adults with physical disabilities?* Yes No Please write about your experience:*School InformationCollege/University Program:*School Location:* City State / Province / Region Degree Expected to Earn:*Expected Date of Graduation:* MM slash DD slash YYYY Do you have a Nursing Advisor?* Yes No Nursing Advisor Name:*Nursing Advisor PhoneNursing Advisor Email* Time at CampCamp dates are Sunday, July 28th through Saturday, August 3rd. Please let us know when you plan on arriving and leaving camp. Note any volunteer who is staying multiple days must be willing to consider a “high” need role such as fire watch, counselor night off or mess hall floors . Desired Days to Volunteer*Please check all the days you will volunteer: Sunday – July 27th, 2025 Monday – July 28th, 2025 Tuesday – July 29th, 2025 Wednesday – July 30th, 2025 Thursday – July 31st, 2025 Friday – August 1st, 2025 Saturday – August 2nd, 2025 Please tell us your arrival day* Saturday – July 26th, 2025 Sunday – July 27th, 2025 Monday – July 28th, 2025 Tuesday – July 29th, 2025 Wednesday – July 30th, 2025 Thursday – July 31st, 2025 Friday – August 1st, 2025 Please estimate your intended arrival time.* Between 6:00 am to 10:00 am Between 10:00 am to 2:00 pm Between 2:00 pm to 6:00 pm Between 6:00 pm to 10:00 pm Between 10:00 pm to 6:00 am (following day) Please tell us your departure day* Monday – July 28th, 2025 Tuesday – July 29th, 2025 Wednesday – July 30th, 2025 Thursday – July 31st, 2025 Friday – August 1st, 2025 Saturday – August 2nd, 2025 Please estimate your intended departure time.* Between 6:00 am to 10:00 am Between 10:00 am to 2:00 pm Between 2:00 pm to 6:00 pm Between 6:00 pm to 10:00 pm Between 10:00 pm to 6:00 am (following day) Will you need housing while volunteering at camp?* Yes No Are you willing to share a room with anyone?* Yes No Is there a particular person you'd like to share a room with?Provide any additional comments or information.Please let us know if there is anything else we need to know about the availability of your volunteer time.Dietary Information:* Gluten Intolerant Lactose Intolerant Vegetarian No Food Restrictions 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.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 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.
