Camp Juliena 2015
Clear Form (Start Over)
Volunteer Application
Deadline For Completed Application: May 15, 2015
Incomplete applications will not be considered.
I would like to volunteer for:
†
I would like to make a donation:
th
th
 Teen Camp (June 27 – July 4 , camper ages 13 – 17)
‡
th
th
 Youth Camp (July 18 – 25 , camper ages 6 – 12)
 I would like to help sponsor a camper
 I would like to make a general donation
 I would like to donate camp supplies
Important Information:
Volunteers are required to attend the trainings described below and may be asked to participate in additional training
before either or both Camp Juliena sessions begin. The Director will notify volunteers with instructions and materials.
Volunteer applicants will be contacted to set up an interview at the director’s discretion.
† Volunteers accepted for Teen Camp Juliena are required to arrive at Camp Lookout at 5pm on June 27th, 2015 for
training. Volunteers may not leave camp facilities without permission from the Director between 1pm June 27th, 2015
and 1pm on July 4th, 2015 after clean-up is complete.
‡ Volunteers accepted for Youth Camp Juliena are required to attend a full day training beginning at 11am on July 18th,
2015 at Camp Viola. Volunteers are not allowed to leave the camp facilities without permission from the Director
between July 19th, 2015 at 1 pm and July 25th, 2015 after clean-up is complete.
NOTE: All Volunteers must pass a background check to be considered. Please send $10 with your application to Camp
Juliena. Signing below gives Camp Juliena permission to obtain your legal records.
Camp Juliena has a ZERO TOLERANCE policy on child abuse and bullying.
Full Legal Name:
Address:
City:
State:
Gender
Level of Hearing Loss
 Male
 Deaf
 Female
 Hard of Hearing
Zip Code:
Phone:
Email:
Birthdate:
 Hearing
T-Shirt Size (Adult Sizes, Choose One):
Soc Sec #:
 Small
Volunteer Signature:
 Medium
 Large
 X-Large
Date:
SEND COMPLETED APPLICATION AND $10 APPLICATION FEE TO:
Camp Juliena
Georgia Council for the Hearing Impaired, Inc.
4151 Memorial Drive, Suite 103-B
Decatur, Georgia 30032
For information, please contact [email protected]
or call Bonna at (770) 856-2492
Camp Juliena: Volunteer Application
Page 1 of 4
Camp Juliena Volunteer Application 2015 - Background Information
Name:
Previous Camp Experience
List all the camps for which you have worked or volunteered (including Camp Juliena):
Name of Camp
Dates worked
Ages of Campers
Paid or Volunteer?
Signing Skills
Your Communication Mode (check all that apply):  ASL  Signed English  Oral English
Your Sign Skill Level:
 Beginner
 Intermediate
 Advanced
 Master
FOR YOUTH CAMP ONLY: Please list desired positions*
Cabin Counselor
Splash/Recreation Team
Nurse
Kitchen Staff
Art/Nature Team
Media team
*We will try meet your preference, but we appreciate your flexibility.
Number top 2 interests.
Place an ‘x’ by least
desired position
Education
Name of Institution
Degree Earned
High School
Technical School/College
College
Employment (Current or Last)
Name of Employer:
Address:
Starting Date:
Leaving Date:
Type of Work:
Reason for Leaving:
References
Name
Address
Have you been convicted of a felony within the last five (5) years?
If yes, please explain (will not necessarily exclude you from consideration):
Phone
Yes
No
I certify that all information on this application is correct. I authorize GACHI/Camp Juliena to verify this information. I understand that
intentionally providing falsified statements on this application shall be grounds for dismissal. I authorize investigation of all
statements contained herein and the references and employer listed above to provide any information concerning my employment. I
understand that my picture/video may be used in camp promotion.
Volunteer’s Signature:
Camp Juliena: Volunteer Application
Date:
Page 2 of 4
Camp Juliena Volunteer Application 2015 - Medical and Emergency Information
Information on this page is not used to select or exclude applicants
Name:
Age:
Weight:
Height:
Hair Color:
Insurance Information
 I have the following type of insurance:  Medical/Hospital
 I do not have health insurance.
Eye Color:
 Medicaid
Name of Insurance:
Policy/Group No:
Current Physician:
Physician Phone:
**Please enclose a copy of your insurance or Medicaid card.**
Emergency Contact Information
Primary Contact
Secondary Contact
Name:
Name:
Relationship:
Relationship:
Phone (Day):
Phone
Phone (Night):
Phone (Night):
Immunizations
Date of Last Tetanus Shot:
(Day):
My Immunizations are up to date:  Yes  No
Current Health History
Allergies
List additional disabilities (physical, mental, psychological):
Drug Allergies:
List other diseases/disorders:
Other Allergies:
List ALL current/chronic conditions:
Food Allergies:
Past Medical Conditions
Please list past medical conditions, surgeries, or injuries:
Physical Limitations/Activity Restrictions:
Medications*
Name of Medication
Dose
Frequency
Route of Admin (how given)
*All prescription/non-prescription drugs and medications must be in their original containers and must be kept in the infirmary or locked away
in approved location at all times. Medications are not to be kept in the cabins. Please leave medications with the health staff before the
campers arrive.
This health history is correct to the best of my knowledge, and I can engage in all camp activities except as noted by me. I understand that
Camp Viola, Camp Lookout, GACHI/Camp Juliena is not liable for any illness or accident incurred during Camp Juliena or during camp activities.
Signature:
Camp Juliena: Volunteer Application
Date:
Page 3 of 4
Camp Juliena Volunteer Application 2015 - Questions
1. What role does Deafness play in the development of campers’ identity?
2. What would your closest friends describe as your strengths and weaknesses?
3. There are times campers don’t want to participate in activities. How would you help encourage them
to join in?
4. A volunteer staff member is on break and notices the water cooler is empty. What do you think that
volunteer should do?
*Please mail completed application and registration forms to:
Camp Juliena
GACHI, Inc.
4151 Memorial Drive Suite 103-B
Decatur, GA 30032
Camp Juliena: Volunteer Application
Page 4 of 4