Camp Rainbow Application 2016

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1 Camp Rainbow Application 2016 Thank you for your interest in being a Camp Rainbow Volunteer! We hope that volunteering for Camp Rainbow will be a life-changing experience for you as you guide a grieving child through an amazing weekend of fun and comfort. Camp Rainbow is brought to you by Mary Washington Hospice Support Care. Camp Rainbow is a weekend day camp for children (Little Buddies) ages 6-14 who have lost a loved one. The goals for Camp Rainbow are to help children understand death and dying, learn to express grief in a healthy way and learn to cope with loss. Art, music, and dance therapy are used to promote these goals alongside traditional camp activities like hiking, kayaking and fireside chats. To provide a rewarding experience, each Little Buddy will be paired with the same Big Buddy for both days. Camp Rainbow will be held at the Virginia Outdoor Center/ Friends of the Rappahannock 3219 Fall Hill Avenue, Fredericksburg, VA Saturday, April 23 and Sunday, April 24 You must be 18 years of age or older to be a Camp Rainbow volunteer. Please complete and return the enclosed packet as soon as possible. Your application must be turned in prior to training. Big Buddy Craft Assistant Please Circle Desired Position: Grief Session Facilitator Meal Prep Assistant R.N./Medic Operations Assistant Circle T - Shirt Size (Adult) S M L XL XXL XXXL Previous Camp Rainbow Experience: Experience working with children: Other children s camp experience (include names and dates): Explain why you wish to volunteer at Camp Rainbow: Are you committed to stay the entire time, both days? Other than English, what languages do you speak? Could you interpret in that language? Age group preference:

2 Please complete the above form and attached application and return both to Mary Washington Hospice Attention: Volunteer Department 2300 Fall Hill Ave, Suite 401 Fredericksburg, VA Camp Rainbow Specific Training is required for ALL Camp Rainbow Volunteers to include returning volunteers. Offered twice during September All those involved in Camp Rainbow are required to attend one of these sessions. Saturday, April 9 from 9:00 a.m. to Noon Saturday, April 16 from 9:00 a.m. to Noon Light Breakfast and Lunch will be served. Training Location: Virginia Outdoor Center, 3219 Fall Hill Ave. Fredericksburg, VA To ensure your name is on the list for the required training, please indicate which training date above you are able to attend by contacting Kathryn Wall, Volunteer Program Support or Camp Rainbow will be held at the Virginia Outdoor Center/ Friends of the Rappahannock 3219 Fall Hill Avenue, Fredericksburg, VA Saturday, April 23 and Sunday, April 24 Big Buddies must commit to both days of Camp Rainbow. Please keep this page for your information. For more information on Camp Rainbow, please contact Kathryn J. Wall at or

3 Mary Washington Healthcare Hospice Support Care Volunteer Application Form 5012 Southpoint Parkway Fredericksburg, VA BUS: (540) FAX: (540) PERSONAL INFORMATION (Please print clearly) Name: Date: Address: City: State/Zip: Telephone: Home: Work: Cell: Date of birth: / / How long at this address? years month The best way to contact me: Home Social Security Number: Are you 18 years or older? Y or N -mail I am available (check all that apply): Mornings Afternoons Evenings Monday Tuesday Wednesday Thursday Friday Saturday Sunday How much time do you have to volunteer? I am a US citizen: Yes No I have been a Virginia resident for years. Person to be notified in case of an emergency: Relationship Home ( ) Work ( ) Occupation/Employer: Address: City: State/Zip: If retired, from what occupation:

4 Education: Level of Education City and State of Institution Years of Study High School Associate Degree Bachelor Degree Graduate Degree Doctorate Technical School Professional School Other(s) Completed Y/N Degree or Certification Are you currently in school? Yes, full-time Yes, part-time No Typing Speed: WPM Microsoft Office: Yes No Professional Licensure: License/Certification State License Number License Issued License Expires Temp or Perm Bereavement History: RELATIONSHIP DATE OF DEATH YOUR AGE CAUSE OF DEATH AREAS OF INTEREST (Check all that apply) Volunteer Opportunities: Family Expressions Grief Support Group Kids Helping Kids In-School Grief Club Camp Rainbow (Grief Camp) Special Events Planning Administrative/Office Support Landscaping/Gardening/Cutting Grass Communication/Marketing Public Relations Fundraising Mass Mailings Working with Children Other

5 EXPERIENCE AND QUALIFICATIONS What type of work have you done in the past? Have you done any volunteer work? Yes, currently yes, in the past No If yes, please specify Are you fluent in any languages? If yes, please list Please describe any life and/or work experiences or training(s) which may help you as a hospice volunteer: Do you have a valid driver s license? Yes No what state? In the past three years have you been convicted of more than three moving violations? Yes No In the past three years have you been in an accident in which you were found to be at fault? Yes No In the past seven years have you been convicted of any major driving offense (DWI, reckless driving, etc.)? Yes No Have you ever been convicted of any criminal violation of law (including minor traffic violations), or are you now under pending investigation or charges of violation of criminal law? Yes No If yes, please describe circumstances, date, and jurisdiction Have you been the subject of any adverse action(s) by any duly authorized sanctioning or disciplinary agency for either conduct based or performance based action? Yes No If yes, please explain In the last three years, have you ever knowingly used any narcotics, amphetamines or barbiturates, other than those prescribed to you by a physician? Yes No If yes, please describe

6 References Have you ever worked for Mary Washington Healthcare or a Mary Washington Healthcare entity? Yes No Are you eligible for employment in the United States? Yes No Do you have relatives employed at Mary Washington Healthcare? Yes No If yes, Name of relative: Please list three references (use form provided to send to your three references to complete.): 1. Name: Address: City: State: Zip Code: Phone: In what capacity and for how long has this person known you? 2. Name: Address: City: State: Zip Code: Phone: In what capacity and for how long has this person known you? 3. Name: Address: City: State: Zip Code: Phone: In what capacity and for how long has this person known you?

7 AGREEMENT AND INFORMATION RELEASE Please read the following carefully before signing. I certify that the answers and statements given by me in response to this application are true and correct with out consequential omissions of any kind whatsoever. I agree that Mary Washington Healthcare shall not be liable in any respect if my volunteer position is terminated because I have falsified statements, or answers, or have made omissions on this application or on supporting documentation. If I volunteer, I hereby agree to abide by the rules and policies of my organization and facilities in which I volunteer as a Hospice Volunteer. I understand that noting contained in the application or during an interview is intended to create a contract between Mary Washington Healthcare and myself for either employment or the provision of any benefits. If a relationship is established, I understand that I have the right to terminate my volunteer position at any time with proper notice, and that Mary Washington Healthcare retains the right to terminate my volunteer position at any time at its discretion. Volunteering is not considered finalized until the Volunteer Coordinator has received: 1. a satisfactory check of references, supporting transcripts and license or registry certification, and criminal background check; 2. a Tuberculosis test must be administered and read, 3. proof of age and citizenship, and all documents necessary to complete federal and state regulatory requirements I hereby authorize Mary Washington Healthcare or the appropriate subsidiary to contact any school, listed reference, law enforcement agencies and persons who may aid Hospice Support Care determining my suitability for a volunteer position unless otherwise noted. Additionally, I release those individuals and/or organizations contacted from all liability whatsoever for providing the requested information. Date: Signature: PARENTAL OR GUARDIAN CONSENT My daughter/son has my permission to serve as a Hospice Support Care Teen Volunteer. SIGNATURE OF PARENT: DATE: Volunteer opportunities are available to all qualified applicants without regard to race, color, religion, gender, national origin, age, disability, or sexual orientation. Hospice shall reserve the right to deny appointment of prospective volunteers as a result of the application, interview and/or training process. applica.vol (HSC)

8 Attention: Volunteers The attached (3) Reference Forms should be returned to the Volunteer Department after they have been completed. No later than April 1, 2016 Please ensure the information for your reference is available on the form, their name, address and phone # in this section at the top of the form: TO: DATE: Please ensure that your name is filled in at the section of the form where it states: Your name has been given as a personal reference by (fill in your name neatly written or typed.) Thank you for your assistance.

9 MARY WASHINGTON HEALTHCARE HOSPICE SUPPORT CARE VOLUNTEER PERSONAL CONFIDENTIAL REFERENCE FORM **************************************************************************************** TO: DATE: Your name has been given as a personal reference by The above named person has applied to be a VOLUNTEER with our program and has given your name as a personal reference. We would greatly appreciate your confidential evaluation of the above-referenced person as to his/her character and ability. Would you kindly fill out and return this information at your earliest convenience. Hospice Support Care (HSC) provides support to people who are grieving. Support services are provided by trained professional. Hospice Support Care uses trained volunteers to provide support to children and families during the bereavement process. Our volunteers work directly with families who are actively grieving. They provide a listening ear and support to families at a very stressful time in their lives. Volunteers are also used to provide support to administrative/office staff and to assist with special events which are held by our agency. Your comments will help our program serve our families more effectively and will be considered confidential. RATE APPLICANT EXCELLENT GOOD AVERAGE POOR Dependability Emotional Stability Interpersonal Skills Punctuality

10 In what capacity have you known the applicant and for how long? Volunteers work with family members under stress. Has this applicant demonstrated stability and strength of character which would permit them to cope with this pressure? YES NO DO NOT KNOW Volunteers work with a variety of people from various religious, ethnic, and cultural backgrounds. Do you feel this applicant demonstrates the ability to be non-judgmental when encountering persons with varying beliefs, values, and/or customs? YES NO DO NOT KNOW Volunteers work with children of all ages. Do you feel this applicant demonstrates the ability to work closely with children? What personal qualities do you feel this applicant demonstrates that would assist him/her in being a volunteer for HSC? If you prefer to discuss this candidate confidentially over the telephone, or would rather convey your impressions personally, please note your phone number: ( ) or call Raquel Woodard, Volunteer Coordinator for Mary Washington Hospice at (540) Please return this form to; Volunteer Coordinator, Mary Washington Hospice, 5012 Southpoint Parkway, Fredericksburg, VA Signature voll-ref.frm (HSC) Date MARY WASHINGTON HEALTHCARE HOSPICE SUPPORT CARE

11 VOLUNTEER PERSONAL CONFIDENTIAL REFERENCE FORM **************************************************************************************** TO: DATE: Your name has been given as a personal reference by The above named person has applied to be a VOLUNTEER with our program and has given your name as a personal reference. We would greatly appreciate your confidential evaluation of the above-referenced person as to his/her character and ability. Would you kindly fill out and return this information at your earliest convenience. Hospice Support Care (HSC) provides support to people who are grieving. Support services are provided by trained professional. Hospice Support Care uses trained volunteers to provide support to children and families during the bereavement process. Our volunteers work directly with families who are actively grieving. They provide a listening ear and support to families at a very stressful time in their lives. Volunteers are also used to provide support to administrative/office staff and to assist with special events which are held by our agency. Your comments will help our program serve our families more effectively and will be considered confidential. RATE APPLICANT EXCELLENT GOOD AVERAGE POOR Dependability Emotional Stability Interpersonal Skills Punctuality

12 In what capacity have you known the applicant and for how long? Volunteers work with family members under stress. Has this applicant demonstrated stability and strength of character which would permit them to cope with this pressure? YES NO DO NOT KNOW Volunteers work with a variety of people from various religious, ethnic, and cultural backgrounds. Do you feel this applicant demonstrates the ability to be non-judgmental when encountering persons with varying beliefs, values, and/or customs? YES NO DO NOT KNOW Volunteers work with children of all ages. Do you feel this applicant demonstrates the ability to work closely with children? What personal qualities do you feel this applicant demonstrates that would assist him/her in being a volunteer for HSC? If you prefer to discuss this candidate confidentially over the telephone, or would rather convey your impressions personally, please note your phone number: ( ) or call Raquel Woodard, Volunteer Coordinator for Mary Washington Hospice at (540) Please return this form to; Volunteer Coordinator, Mary Washington Hospice, 5012 Southpoint Parkway, Fredericksburg, VA Signature voll-ref.frm (HSC) Date MARY WASHINGTON HEALTHCARE HOSPICE SUPPORT CARE

13 VOLUNTEER PERSONAL CONFIDENTIAL REFERENCE FORM **************************************************************************************** TO: DATE: Your name has been given as a personal reference by The above named person has applied to be a VOLUNTEER with our program and has given your name as a personal reference. We would greatly appreciate your confidential evaluation of the above-referenced person as to his/her character and ability. Would you kindly fill out and return this information at your earliest convenience. Hospice Support Care (HSC) provides support to people who are grieving. Support services are provided by trained professional. Hospice Support Care uses trained volunteers to provide support to children and families during the bereavement process. Our volunteers work directly with families who are actively grieving. They provide a listening ear and support to families at a very stressful time in their lives. Volunteers are also used to provide support to administrative/office staff and to assist with special events which are held by our agency. Your comments will help our program serve our families more effectively and will be considered confidential. RATE APPLICANT EXCELLENT GOOD AVERAGE POOR Dependability Emotional Stability Interpersonal Skills Punctuality

14 In what capacity have you known the applicant and for how long? Volunteers work with family members under stress. Has this applicant demonstrated stability and strength of character which would permit them to cope with this pressure? YES NO DO NOT KNOW Volunteers work with a variety of people from various religious, ethnic, and cultural backgrounds. Do you feel this applicant demonstrates the ability to be non-judgmental when encountering persons with varying beliefs, values, and/or customs? YES NO DO NOT KNOW Volunteers work with children of all ages. Do you feel this applicant demonstrates the ability to work closely with children? What personal qualities do you feel this applicant demonstrates that would assist him/her in being a volunteer for HSC? If you prefer to discuss this candidate confidentially over the telephone, or would rather convey your impressions personally, please note your phone number: ( ) or call Raquel Woodard, Volunteer Coordinator for Mary Washington Hospice at (540) Please return this form to; Volunteer Coordinator, Mary Washington Hospice, 2300 Fall Hill Ave, Suite 401, Fredericksburg, VA Signature voll-ref.frm (HSC) Date

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