April 10, 2015
Dear Prospective Camp Pascucci Staff Member,
You have been chosen to join our tribe. This year’s camp theme is Survivor. Grab your buffs and make your way
to the mountains for HASDC’s Camp Pascucci as we outwit, outplay and outlast. Our camp is specially designed
for youth ages 7-14 with a bleeding disorder, diagnosed carriers and siblings. Camp will be held June 15-20, 2015
at YMCA Camp Whittle in Big Bear (about 2 hours from San Diego).
Enclosed you will find the 2015 Camp Pascucci Staff Application. All camp positions are unpaid and voluntary.
Please complete the enclosed forms and return them to the Hemophilia Association of San Diego County
(HASDC) no later than Friday, May 15, 2015. Please note that staff members with a bleeding disorder must
submit a physical. The Physician’s Form must be completed by a hematologist. As it can sometimes take several
weeks to get an appointment with a doctor, please do not wait until the last minute to schedule an appointment
with your physician.
Staff space is limited, therefore it is important to please submit your application by the deadline. If we do not
receive your completed application on or before May 15, 2015, you will not be considered as camp staff during
our 2015 camping season.
Once your application is received, you will receive an email from HireRight with directions for a background
check. The background check is required to be considered for a camp staff position.
HASDC will contact you by May 31st to inform you of your acceptance as a Camp Pascucci staff member, pending
our required background check. The acceptance packet will then be mailed, containing additional information
regarding camp check-in times, location, transportation, etc. Please note: staff training will take place Sunday,
June 14 and is mandatory for all staff members. If you have any questions prior to the camp start date, please
call the office.
In the end, only one team will remain to claim the ultimate prize, the title of sole SURVIVOR. We look forward to
having you participate in our 2015 camping season.
Sincerely,
Nooshin Kosar
Executive Director
3550 Camino Del Rio North, Suite 105San Diego, CA 92108PH: 619.325.3570FAX: 619.325.4350www.hasdc.org
STAFF TRAINING & REGISTRATION MATERIALS
Self-Assessment
Can you take the time to make a difference?
Mandatory staff arrival and training: Sunday, June 14, 2015
Camp Pascucci: Monday, June 15 - Saturday, June 20, 2015.
Since you are inquiring about a staff position with Camp Pascucci, it means that you possess a caring and
compassionate nature. All camp positions require a significant commitment outside of camp. Sometimes staff
with good intentions and great ideas are simply too busy to follow through on their commitment. This can
result in a disappointed camper. With this in mind, we are counting on you to follow through with the
commitments you make to the camp in addition to the other commitments in your life.
You understand that you will check your personal life upon arrival and fully participate in camp for the entire
week. You understand that there will be no cell coverage/usage, no access to email, limited sleep and plenty of
singing! Please consider this carefully before you apply.
Can you go with the flow?
The physical environment in which we live at camp is different than what we are used to in our everyday lives.
In addition to the uniqueness of the physical environment, we continually challenge camp staff to reach new
heights of personal growth that will then help them lead campers to the best possible camp experience.
Though this unique environment can be challenging, it is part of what makes it such a rewarding experience for
staff.
Can you go the extra mile?
At Camp Pascucci, we strive to make camp a life-enriching experience for all who attend, campers and staff
alike. We strongly urge staff to spend time before camp honing their counseling skills by learning new camp
songs, child management techniques, leadership skills, and technical skills. To what length are you willing to go
in order to be the best camp counselor, JRC, or general staff person that you can be?
Thanks for considering these important questions! Every staff person is important to the mission of Camp
Pascucci and the campers rely on YOU for this extraordinary experience. If after answering these questions to
yourself, camp seems like it is a good fit for you, then please complete the registration materials.
Camp Registration Materials
Please return the following items by May 15:
1. Staff Application
2. Medical History
3. Consent Form
4. YMCA Liability & Indemnity Agreement
5. Camp Rules
6. Physician’s Form – for persons with bleeding disorders ONLY, completed by applicant’s hematologist
For identification
purposes, please
Staff Application 2015
attach your photo
Camper Pascucci
here.
IS THIS YOUR FIRST TIME AT CAMP?
YES
NO
IF THIS IS YOUR FIRST TIME, HOW DID YOU HEAR ABOUT US? ____________________________________
APPLICANT’S AREA OF INTEREST (check which position(s) you are interested in):
Detailed position descriptions can be found at the end of the application.
□ Senior Camper (15 years)
□ Co-Director (18+)
□ Junior Counselor (16 - 17 years)
□ General Volunteer (15+)
□ Counselor (18+)
□ Medical Staff
Applicant General Information
Applicant’s Name: _________________________ ________________________
FIRST
Gender: □ Male □ Female
LAST
Address: ____________________________________ City: ___________________ State: ____ Zip: _________
Home Phone: ________________________________
Cell Phone: ________________________________
Email: ____________________________________________________________________________________
Date of Birth: _____ /_____ /_____
Age (as of June ‘15): ______
Highest Level of Education: _________
Employer: _______________________________ Position: _______________________ Phone: ____________
Parent/Guardian Information (if under 18)
First Name
Address (if different from above)
Parent/Guardian
#1
Home Phone
(
)
Employer
First Name
Address (if different from above)
Parent/Guardian
#2
Home Phone
(
)
Employer
Last Name
Relationship to Applicant
City
State/Zip
Cell Phone
(
)
Last Name
Evening Phone
(
)
Work Phone
(
)
Relationship to Applicant
City
State/Zip
Cell Phone
(
)
Evening Phone
(
)
Work Phone
(
)
Application Pg. 1
Applicant lives with:
□ Both Parents
□ Mother
□ Father
□ Other: ___________________
Emergency Contact Information
Emergency
Contact #1
Emergency
Contact #2
First Name
Last Name
Relationship to Applicant
Address (if different from above)
City
State/Zip
Home Phone
(
)
Employer
Cell Phone
(
)
First Name
Last Name
Evening Phone
(
)
Work Phone
(
)
Relationship to Applicant
Address (if different from above)
City
State/Zip
Home Phone
(
)
Employer
Cell Phone
(
)
Evening Phone
(
)
Work Phone
(
)
Employment History
Most Recent/Current Job
Company/Employer: ________________________________________________________________________
Start Date: __________________________________
End Date: _________________________________
Employer: _____________________________ Position: _____________ Supervisor: ____________________
Work Address: ______________________________ City: _________________ State: ______ Zip: _________
Phone: ____________________________________
Prior Job
Company/Employer: ________________________________________________________________________
Start Date: __________________________________
End Date: _________________________________
Employer: _____________________________ Position: _____________ Supervisor: ____________________
Work Address: ______________________________ City: _________________ State: ______ Zip: _________
Phone: ____________________________________
Application Pg. 2
Volunteer/Childcare Experience
Have you had previous volunteer or childcare experience? □ Yes □ No
If yes, please use the space below to describe. Provide the name of the organization along with your
supervisor, relevant dates and the position held.
Organization: _____________________________________ Position: __________________________________
Supervisor’s Name: ____________________________ Duration: ____________ Phone: ___________________
References
Do not list current employers, relatives or HASDC staff as references. Suggested references include past
employers, co-workers, fellow volunteers, babysitting employers, etc. If you are a returning volunteer to Camp
Pascucci, you are welcome to list a fellow volunteer of a prior camp as only one of the three references
required. Please note: references will be contacted therefore please verify that contact information is current.
Reference #1
First Name
Last Name
Relationship to Applicant
Address (if different from above)
City
State/Zip
Home Phone
(
)
Employer
Cell Phone
(
)
First Name
Last Name
Evening Phone
(
)
Work Phone
(
)
Relationship to Applicant
Address (if different from above)
City
State/Zip
Home Phone
(
)
Employer
Cell Phone
(
)
Evening Phone
(
)
Work Phone
(
)
Reference #2
Application Pg. 3
Sibling/Relative Also Attending Camp
First & Last Name
Age
Relationship to Applicant
Transportation
Please choose a drop off location where you will be dropped off to go to camp as well as a pick-up after camp
location where you will be picked up at the end of the camping week. You will receive the drop off and pick-up
times for your selected locations in your acceptance packet.
Drop-off for Staff Training (Sunday, June 14)
Pick-up after camp (Saturday, June 20)
□ HASDC Office
□ HASDC Office
□ YMCA Camp Whittle (Big Bear)
□ YMCA Camp Whittle (Big Bear)
T-Shirt Size (check only one box)
Youth Size:
□ Large
Adult Size:
□ Small
□ Medium
□ Large
□ X-Large
□ XX-Large
Counseling Preference (if applicable)
Please indicate which age group(s) you think you would work best with/prefer to work with.
□ 7-8 year olds
□ 9-10 year olds
□ 11-12 year olds
□ 13-14 year olds
□ 15 year olds
Certifications/Trainings Completed
CPR Certified:
First Aid Training:
Lifeguard:
□ Yes
□ Yes
□ Yes
□ No
□ No
□ No
Date of Certification: _____________________
Date of Certification: _____________________
Certificate Number: ____________ Exp Date: _______________
Medical Staff Only
Type of Licensed Medical Professional: _________________________________________________________
License Number: _________________ State Where Licensed: _______ License Expiration Date: ___________
Application Pg. 4
MEDICAL HISTORY
(COMPLETED BY PARENT/GUARDIAN IF UNDER 18)
Applicant’s Name: __________________________________________________________________________
Date of Birth: ______ /______ /______
Height: ____________
Weight: ____________
Hemophilia Treatment Center/Physician Information
Hematologist
Pediatrician/Physician
HTC
Institution
Address
Address
City
State
Zip
City
Phone
(
)
□ Unaffected Applicant (leave above blank)
State
Zip
Phone
(
)
Diagnosis
Factor
Deficiency
□ Factor 8
□ vWD2b
□ Factor 9
□ vWD2c
□ vWD1
□ Carrier 8
□ vWD2
□ Carrier 9
□ vWD2a
□ Other: _____________________
Severity
□ Mild
□ Moderate
□ Severe
Inhibitor
□ Yes
□ No
□ Date of last inhibitor test ______ /______ /______
Treatment
Do you/child self-infuse?
□ Yes (independently)
□ Yes (needs help)
Do we have permission to teach your child (if under 18) to self-infuse?
□ No (but would like to learn)
□ Yes
□ No
Factor Name: _______________________
Are you/child on prophylaxis?
□ Yes □ No
If yes, please indicate dosage schedule for camp:
Mon:______ Units Tues:______ Units Wed:______ Units Thur:______ Units Fri:______ Units Sat:______ Units
If no, please indicate dosage of factor and send enough for at least 3 days of a major bleed
Dosage: _________________
Medical History Pg. 1
Other Medical Conditions
□ ADD/ADHD
□ Heart Defect
□ Allergies
□ Epilepsy/Seizures
□ Asthma
□ Diabetes
□ Bedwetting
□ Trouble Sleeping
□ Head lice recently □ Other: _________________
Allergies
Drug allergy: ________________ Type of Reaction: ________________ Treatment: ______________________
Drug allergy: ________________ Type of Reaction: ________________ Treatment: ______________________
Food allergy: ________________ Type of Reaction: ________________ Treatment: ______________________
Food allergy: ________________ Type of Reaction: ________________ Treatment: ______________________
Behavioral Concerns
□ Shyness
□ Psychological
□ Anger Management
□ Other: ___________________
Medications
All medications administered at camp (including over the counter and vitamins) must appear on your medical
form. Please send all medications necessary for the week in their original bottles. We will NOT accept pill boxes
or any medication not in their original packaging. Camp medical staff will store and administer medications as
directed by you. This includes any allergy medications, vitamins, ibuprofen, etc.
Medication
Dose
Mon
Tue
Wed
Thur
Fri
Sat
□ as needed
□ as needed
□ as needed
□ as needed
Medical History Pg. 2
Immunizations
Please note: All campers/staff must be fully vaccinated to attend Camp Pascucci. Complete or include a copy of
immunization records.
Immunization
Chicken Pox (Varicella)
DTaP
Hepatitis A
Hepatitis B
HPV
Influenza
MMR
Meningococcal
Pneumococcal
Polio
Rotavirus
Tdap
□ Dose 1
□ Dose 1
□ Dose 1
□ Dose 1
□ Dose 1
□ Dose 1
□ Dose 1
□ Dose 1
□ Dose 1
□ Dose 1
□ Dose 1
□ Dose 1
Schedule
□ Dose 2
□ Dose 2 □ Dose 3 □ Dose 4
□ Dose 2
□ Dose 2 □ Dose 3
□ Dose 2 □ Dose 3
□ Dose 2
□ Dose 2
□ Dose 2
□ Dose 2
□ Dose 2
Date Completed
□ Dose 3 □ Dose 4
□ Dose 3 □ Dose 4
Additional Questions
Does you/child know how to swim?
□ Yes
□ No
Does you/child use a wheel chair?
□ Yes
□ No
Does you/child have any dietary restrictions?
□ Yes
□ No
□ if yes, please list: ____________________________________________________________________
Have you/child ever been away from home?
□ Yes
□ No
Have you/child experienced any stressful life events in the past year?
□ Yes
□ No
□ if yes, please explain: _________________________________________________________________
Have you/child ever seen a therapist or psychiatrist?
□ Yes
□ No
□ if yes, please explain: _________________________________________________________________
Insurance
□ Check here if you/your child does not have insurance
If you have health and accident insurance coverage, please provide the following information:
Name of Insurance Company: ______________________________
Insurance Company phone: ________________________________
Policy Number: ________________________
Certificate Number: ________________________
CCS Number: __________________________
MediCal Number: __________________________
Medical History Pg. 3
CONESENT FORM
(COMPLETED BY PARENT/GUARDIAN IF UNDER 18)
Infusion Instruction Consent (for bleeders, carriers & siblings)
At Camp, we will be offering self-infusion classes to campers and staff, carriers and siblings on a voluntary and
individual basis by our medical staff. You/child could receive this important training when he/she needs factor
replacement during camp, but only if you/child are voluntarily ready to infuse himself, herself or sibling.
My signature below indicates my consent/consent for my child to receive infusion instruction.
Applicant/Guardian (if under 18) Signature: ___________________________________ Date: ______________
Factor Usage Consent
I want my child to use only physician-designated factor while at Camp, and I will be responsible for supplying an
adequate amount of factor for the week of Camp. I understand that every reasonable effort will be made to
give my child only his/her designated factor. However, I realize the possibility exists that an unusual medical
emergency or situation may require that my child use donated factor, which may not be the same brand, purity
or assay, and may be a plasma-derived (non-recombinant) product. If this situation occurs, I understand Camp
medical staff will authorize the appropriate factor usage, which will be fully documented in my child’s medical
log. I hereby release HASDC, YMCA Camp Whittle and their respective agents, employees and representatives
from any claim whatsoever as a result of providing donated factor during camp.
□ Check here if not applicable (meaning that you/child do not have a bleeding disorder)
My signature below indicates my consent for myself/child to receive donated factor during camp.
Parent/Guardian (if under 18) Signature: _______________________________________ Date: ____________
Permission to take photographs
I hereby give consent for photographs and/or motion pictures of myself/child to be used for any of the
following purposes: HASDC publicity, public service announcements on television or the internet, publicity with
supporting agencies, scholarship awards, camp promotion or any other agency-approved and supported
activity.
My signature below indicates my consent for HASDC to use photographs of myself/child taken at camp.
Applicant/Guardian (if under 18) Signature: ____________________________________ Date: _____________
Luggage Search
I agree that my/child’s belongings may be searched outside the applicant’s presence for electronics, food,
candy, drugs, alcohol, weapons or other forbidden objects if there is suspicion of objects being present.
My signature below indicates my consent for myself/child’s luggage to be searched if necessary.
Parent/Guardian (if under 18) Signature: _______________________________________ Date: _____________
Consent Form Pg. 1
CONFIDENTIALITY AGREEMENT
Initial ______ I will respect the confidentiality of the participants and will not use any access I may have to their
names, addresses, telephone, e-mail, etc. for personal gain now or at any time in the future.
HASDC Camp Procedures/Guidelines
The Executive Director of the Hemophilia Association of San Diego County shall appoint Camp
Directors at his/her discretion, who will be responsible for all staff, personnel and volunteers while at camp.










Applicants understand that space is limited and therefore not everyone will be chosen.
All camp volunteers and personnel will be chosen and approved by HASDC staff.
All volunteers must pass a background check, an interview and provide three individual references.
If there is any dispute at the camp, it shall be resolved at the discretion of the Camp Directors.
There will be one person appointed as Chief Medical Staff In-Charge at all times during the camp week.
There will be no access to electronic devices such as cell phones and laptops. If you do bring electronic
devices they will be held for you by the Camp Directors and returned at the end of the week.
There will be no pictures taken by camp volunteer staff. HASDC will take care of photography and post all
photos on our website and Facebook page.
Camp staff are not allowed to friend campers on Facebook. If this occurs, it can affect your attendance in the
future.
The use of Camp Pascucci materials including but not limited to camp logo, photographs, articles from its
newsletter(s), event fliers, and its website – are expressly prohibited without advance written approval
(electronic mail and faxes are acceptable) from Camp Pascucci.
Any person or persons who refuse to abide by the guidelines set forth (including rules, regulations,
procedures, mission, philosophy, etc.) will be asked to leave the Camp.
Initial ______ I have read and agree to comply with the following summer camp procedures listed above. I
understand I will be asked to leave camp if I do not honor my agreement.
Consent Form Pg. 2
Release of Liability & Authorization for Emergency Medical/Dental Treatment
I, __________________________________, am the parent/ legal guardian of a camper, counselor-in-training,
or junior counselor (if under 18 years old), or a participant (over 18 years old) who will travel to and attend
Camp Pascucci (hereinafter the Camp), at YMCA Camp Whittle, sponsored by the Hemophilia Association of
San Diego County. I understand that the activities involved in Camp will pose the risk of harm or injury. On my
own behalf, and on behalf of my child or ward, I hereby freely and expressly consent to release, discharge,
indemnify and hold harmless, YMCA Camp Whittle, the Hemophilia Association of San Diego County, and their
respective agents, employees, and representatives from any damage, claims, loss, or injury sustained by me or
my child/ward while traveling to or from the Camp, while attending or participating in any activities at Camp, or
any other trips or activities sponsored by the Hemophilia Association of San Diego County. This release includes
within its scope any damage, loss or injury sustained as a result of any ordinary negligence, whether active or
passive on the part of YMCA Camp Whittle, the Hemophilia Association of San Diego County, or any of their
respective agents, employees or representatives.
As the parent/guardian of the camper, counselor-in-training, junior counselor, or as a participant, I hereby give
my consent to any medical treatment, including any examination, X-ray, anesthetic, medical or surgical
diagnosis or treatment, or hospital care to be rendered to me or my child/ward under the general or special
provisions of the Medical Practice Act, or to consent to any dental treatment, including any examination, X-ray,
anesthetic, dental or surgical diagnosis or treatment, or hospital care to be rendered to me or my child/ward by
a dentist licensed under the provisions of the Dental Practice Act. This authorization shall be effective while I or
my child/ward is en-route to or from Camp, or involved or participating in any program or activity of Camp, or
under the supervision of any personnel associated with the Camp, regardless of the location where treatment
or care is rendered, unless earlier revoked by me in writing and delivered to the Camp Director.
The foregoing release is to be construed in accordance with the laws of the State of California. It is intended to
release claims which are not yet known. Accordingly, I hereby waive, on my own behalf, and on behalf of my
child/ward, the provisions of California Civil Code §1542, which provides:
“A general release does not extend to claims which the creditor does not know or suspect
to exist in his favor at the time of executing the release, which if known by him must have
materially affected his settlement with the debtor.”
I have read and understood this Release and Authorization and the attached Medical History and Information
Form, and the information I have given is true and correct. PHOTOSTATIC COPIES OF THIS RELEASE AND
AUTHORIZATION WILL BE CONSIDERED AS VALID AS THE ORIGINAL.
Signature (parent/guardian/participant if over 18): __________________________________ Date: _________
Print name: ____________________________________ Applicant Name: _____________________________
Consent Form Pg. 3
YMCA CAMP WHITTLE
Liability & Indemnity Agreement
YMCA Liability Form Pg. 1
CAMP RULES
Please be sure that you know and agree to the following camp rules before coming to camp. All campers and
staff must abide by camp rules for the duration of the camping week. Campers and staff not following camp
rules may be asked to leave camp and transportation must be provided by applicant/parent or guardian.
GENERAL
 DO NOT bring food, candy or drinks with you. If found, items will be confiscated.
 Electronic equipment of any kind (handheld games, MP3 players, TV’s, Stereos, Cell Phones, etc.) are
prohibited at camp. Camp staff will confiscate them. Parents, please keep these items at home!
 Wear shoes at all times. NO SANDALS OR OPEN TOED SHOES AT CAMP!
 Throwing rocks (or any object) could injure someone – don’t throw anything at camp.
 No weapons (knives, guns, sling-shots, other weapons, etc.) are ever allowed at camp at any time.
 You must be accompanied by a staff person at all times.
 Follow the buddy system – you should ALWAYS have a buddy with you.
 You must stay on the camp grounds at all times. Leaving is not permitted.
 No water balloons as they can cause injuries – water games take place in an organized fashion or at the
pool only.
 No visitors are allowed at any time, without expressing prior permission from our Camp Director.
CABIN RULES
 Stay with your cabin group. Get permission from a counselor before entering another cabin.
 Respect the space and property of others – stay out of other campers’ belongings.
 Graffiti (carved or written) is vandalism. We (you) will pay for all damages to camp property.
 Counselors and campers will jointly make up additional rules for their cabins– follow these!
RESPECT
 Observe the A. D. S. rules at camp – NO Alcohol, NO Drugs, NO Sex at Camp. EVER.
 This is a non-smoking camp. No smoking is allowed anywhere on camp grounds.
 Please treat all campers and staff with respect. Teasing, swearing, inappropriate jokes and rude behavior
are unacceptable - inappropriate behavior will result in contacting camper’s parent/guardian.
ENVIRONMENT
 Preserve the environment – throw away your garbage and recycle when possible.
 Be kind to animals – they live here, we are only visiting.
 Please stay out of the kitchen area unless you are assigned to be a helper.
 Trees are living creatures too – please respect them by not climbing or pulling out their leaves.
My signature and applicant’s signature below indicates my/our understanding of the above rules. If rules are
violated it may result in myself/child being sent home.
Guardian (if under 18) Signature: _____________________________________ Date: _____________________
Applicant Signature: _______________________________________________ Date: _____________________
Camp Rules Pg. 1
PHYSICIAN’S FORM
(COMPLETED BY HEMATOLOGIST OR PHYSICIAN)
Please note: physician signature is required
Camper/Staff Name: _________________________________________ Date of Birth: ______ /______ /______
Date of last exam: ______ /______ /______
Bleeding Disorder:
□ Yes
Weight: ______ lb.
Height: ______ ft.
□ Male
□ Female
□ No
Diagnosis
Factor
Deficiency
□ Factor 8
□ vWD2b
□ Factor 9
□ vWD2c
□ vWD1
□ Carrier 8
Severity
□ Mild
□ Moderate
□ Severe
□ vWD2
□ Carrier 9
□ vWD2a
□ Other: ____________________
Factor
Activity Level _______________ %
Inhibitor
□ Yes
□ No
□ Date of last inhibitor test ______ /______ /______
HIV Status
□ Positive
□ Negative
□ On HIV medications
Hep C Status
□ Positive
□ Negative
□ On Hep C medications
Treatment
Factor Name: _______________________
Routine Dose: ____________ Units or ____________ U/kg
Does camper/staff self-infuse? □ Yes (independently)
□ Yes (needs help)
Does camper/staff use EMLA prior to infusing? □ Yes
□ No
DDAVP/Stimate used? □ Yes
□ No
Amicar used? □ Yes
□ No (but would like to learn)
□ No
Target joints:
□ Yes
□ No
□ If yes, state which joints: ___________________________
Does camper/staff have a Portocath or Brovic/Hickman? □ Yes □ No
Can they go swimming? □ Yes □ No
Is camper/staff on prophylaxis?
□ Yes □ No
If yes, please indicate dosage schedule for camp week:
Mon:______ Units Tues:______ Units Wed:______ Units Thur:______ Units Fri:______ Units Sat:______ Units
Medications
Medication
Dose
Mon
Tue
Wed
Thur
Fri
Sat
□ as needed
□ as needed
□ as needed
Physician Form Pg. 1
PHYSICIAN’S FORM Continued
Camper/Staff Name: ____________________________________________
Physical Exam
Area of Interest
Abdomen
Cardiac
Chest
Dental
Ears, Nose & Throat
Extremities
Eyes
Head
Neuro
Skin
Please check one
□ Normal
□ Abnormal
□ Normal
□ Abnormal
□ Normal
□ Abnormal
□ Normal
□ Abnormal
□ Normal
□ Abnormal
□ Normal
□ Abnormal
□ Normal
□ Abnormal
□ Normal
□ Abnormal
□ Normal
□ Abnormal
□ Normal
□ Abnormal
Explain any abnormalities
Allergies
Drug allergy: ________________ Type of Reaction: ________________ Treatment: ______________________
Drug allergy: ________________ Type of Reaction: ________________ Treatment: ______________________
Food allergy: ________________ Type of Reaction: ________________ Treatment: ______________________
Food allergy: ________________ Type of Reaction: ________________ Treatment: ______________________
Immunizations
Please note: All campers/staff must be fully vaccinated to attend Camp Pascucci. Complete or include a copy of
immunization records.
Immunization
Chicken Pox (Varicella)
DTaP
Hepatitis A
Hepatitis B
HPV
Influenza
MMR
Meningococcal
Pneumococcal
Polio
Rotavirus
Tdap
□ Dose 1
□ Dose 1
□ Dose 1
□ Dose 1
□ Dose 1
□ Dose 1
□ Dose 1
□ Dose 1
□ Dose 1
□ Dose 1
□ Dose 1
□ Dose 1
Schedule
□ Dose 2
□ Dose 2 □ Dose 3 □ Dose 4
□ Dose 2
□ Dose 2 □ Dose 3
□ Dose 2 □ Dose 3
□ Dose 2
□ Dose 2
□ Dose 2
□ Dose 2
□ Dose 2
Date Completed
□ Dose 3 □ Dose 4
□ Dose 3 □ Dose 4
Physician Form Pg. 2
PHYSICIAN’S FORM Continued
Camper/Staff Name: ____________________________________________
Psychosocial
Is the camper’s/staff member’s development appropriate for his/her age? □ Yes □ No
□ if no, please explain: _________________________________________________________________
Other
Recent surgery or illness: □ Yes □ No
□ if yes, please explain: _________________________________________________________________
Recent contact with a contagious disease: □ Yes □ No
□ if yes, please explain: _________________________________________________________________
Any special instructions?
□ Yes □ No
□ if yes, please explain: _________________________________________________________________
Physician Contact Information
Physician name: ________________________________________ Office/Clinic Name: ___________________
Address: ____________________________________ City: __________________ State: ______ Zip: ________
Phone: _____________________________ After hours/Emergency Phone: ____________________________
My signature below indicates I/my staff has completed the above Physician’s Form for Camp Pascucci.
Physician’s Signature (mandatory): _________________________________________ Date: ______________
Please Print Name: ______________________________________________________
Physician Form Pg. 3
APPLICANT INFORMATION
(Please keep this information for your use during preparation for camp)
Packing Directions
MEDICATIONS
 All medications should be in their original containers, then packed in Ziploc baggies clearly labeled with
applicant’s first and last name.
 Medications must be given to camp nurse at check-in, DO NOT pack medications in your suitcase.
 All applicants with a bleeding disorder must bring enough of their own factor and infusion supplies to
cover treatments for an active week of camp, PLUS 2 DOSES IN CASE OF AN EMERGENCY.
 Note: Camp supplies of concentrates, if available at all, are extremely limited and will be sued for
emergencies only. Not all brands of factor will be available - we do not expect to have any recombinant
product on hand at camp. Donated product will likely be plasma-derived (non-recombinant) product.
PERSONAL ITEMS
 Applicants are limited to one (1) duffle bag or suitcase, one (1) pillow and one (1) sleeping bag - each
item must be clearly labeled with camper’s first and last name.
 Applicants should be able to carry all of their own supplies without assistance, please do not pack more
than you can carry.
COMMUNICATION
Mail from home: mail call is an important camp event. If you wish to send mail, please mail your
letter/postcard that day camp begins or earlier to ensure its arrival during the week of camp. You can send mail
to the following address:
YMCA Camp Whittle
Attn: Hemophilia – Your Child’s Full Name
P.O. Box 70
Fawnskin, CA 92333
Telephone calls: Electronics, especially cell phones are not allowed during the week of camp. Phone calls are
only to be made in the event of an emergency. If you should need to reach staff during the week of camp you
can call the HASDC office at 619.325.3570 or YMCA Camp Whittle at 909.866.3000.
Visitation: Visitations during the week of camp are not allowed.
Expectations: all staff members are expected to stay, be present and work the entire week of camp. Leaving
camp grounds is prohibited. Breaks are allotted throughout the day by the camp director. Remember, as staff
that you are the example and often times mentor to the campers, therefore it is important to always be on
your best behavior and to use appropriate language.
CAMP PACKING LIST
What to Bring to Camp
Attention applicant: Please be sure you have everything listed below. Each applicant is limited to one (1) duffle
bag or suitcase - don’t pack more than you can carry.
Clothing:
 Shorts (3-4)
 T-shirts (6)
 Shoes (two pairs, including good sneakers or
hiking boots)
 Long Pants and/or sweats (2)
 Underwear (6)
 Warm sweatshirt or light jacket (1)
 Socks (7)
 Pajamas (1)
 Hat (1)
 Swimsuit (1)
 Note: no open toed shoes
Toiletries:
 Toothbrush
 Toothpaste
 Brush or Comb
 Shampoo
 Soap
 Chapstick
 Insect repellent
 Sunscreen
Bedding:
 Sleeping bag (1) or bedding
 Pillow (1)
 Pillow case (1)
 Twin fitted sheet (1)
Other:
 Towel for swimming & showering- labeled with
name
 Reusable water bottle- labeled with name
Optional:
 Flashlight
 Flip flops for shower
 Water shoes for lake activities
 Pen/paper/stamps
 Costumes/props for Survivor camp theme
 Books or magazines
Staff Suggestions:
 “Survivor” decorations for cabin
 Additional theme related items for cabin/campers
Things to Leave at Home
Please leave the following items at home as there are prohibited at camp:
 Cell phones
 Food/Candy/Snacks
 DS or other handheld games
 iPods or other music devices
 Laptops/tablets
 Knives/weapons of any kind
 Matches
 Money
 Open toed shoes/sandals (except flip flops for shower)
 Revealing or offensive clothing (no midriff baring shirts, no shirts with inappropriate language or
images)
CAMP RULES
Please be sure that you/child know and agree to the following camp rules before coming to camp. All campers
and staff must abide by camp rules for the duration of the camping week. Campers and staff not following
camp rules may be asked to leave camp and transportation must be provided by applicant, parent or guardian.
GENERAL
 DO NOT bring food, candy or drinks with you. If found, items will be confiscated.
 Electronic equipment of any kind (handheld games, MP3 players, TV’s, Stereos, Cell Phones, etc.) are
prohibited at camp. Camp staff will confiscate them. Parents, please keep these items at home!
 Wear shoes at all times. NO SANDALS OR OPEN TOED SHOES AT CAMP!
 Throwing rocks (or any object) could injure someone – don’t throw anything at camp.
 No weapons (knives, guns, sling-shots, other weapons, etc.) are ever allowed at camp at any time.
 You must be accompanied by a staff person at all times.
 Follow the buddy system – you should ALWAYS have a buddy with you.
 You must stay on the camp grounds at all times. Leaving is not permitted.
 No water balloons as they can cause injuries – water games take place in an organized fashion or at the
pool only.
 No visitors are allowed at any time, without expressing prior permission from our Camp Director.
CABIN RULES
 Stay with your cabin group. Get permission from a counselor before entering another cabin.
 Respect the space and property of others – stay out of other campers’ belongings.
 Graffiti (carved or written) is vandalism. We (you) will pay for all damages to camp property.
 Counselors and campers will jointly make up additional rules for their cabins– follow these!
RESPECT
 Observe the A. D. S. rules at camp – NO Alcohol, NO Drugs, NO Sex at Camp. EVER.
 This is a non-smoking camp. No smoking is allowed anywhere on camp grounds.
 Please treat all campers and staff with respect. Teasing, swearing, inappropriate jokes and rude behavior
are unacceptable - inappropriate behavior will result in contacting camper’s parent/guardian.
ENVIRONMENT
 Preserve the environment – throw away your garbage and recycle when possible.
 Be kind to animals – they live here, we are only visiting.
 Please stay out of the kitchen area unless you are assigned to be a helper.
 Trees are living creatures too – please respect them by not climbing or pulling out their leaves.
POSITION DESCRIPTIONS
POSITION TITLE:
SUPERVISOR:
Senior Camper
Counselor in Assigned Cabin
GENERAL FUNCTION:
To participate under the supervision of the Senior Camper Counselor in planning or implementing activities. Activities are
planned for 7-14 year olds in a camping program for children, carriers and siblings affected by bleeding disorders. To
actively interact with children while providing a positive young adult role model. To promote and encourage their
individual growth.
SKILLS:
Applicant must be 15 years old (applicant must turn 15 years old by June 2015). Past work with children, including
siblings in a recreational or educational setting is desirable. Previous babysitting experience is a plus. An interest in
leadership skills and willingness to learn and understand organizational skills and group dynamics. Ability to and interest
to help professional staff lead a variety of recreational activities including: sports, games, creative arts and environmental
education, and to assist with the implementation of private HASDC camp activities as needed. Ability to perform under
stress/pressure while remaining flexible. Ability to recognize the importance of safety at all times. Genuine interest in
working with people a must.
JOB SEGMENTS:
A. PROGRAM DEVELOPMENT
 As part of a group, work with Senior Counselors and professional staff to carry out recreational activities for 7-14
year olds in a camping program.
 Stay with your assigned group at all times unless previous arrangements have been made with the Senior Camper
Counselor.
 In leading activities, encourage kids to take responsibility (i.e., clean up after themselves, etc.)
 Follow all HASDC and program policies, as well as legal guidelines.
 Attend all staff training events.
 Report all accidents to the Senior Counselor, who must report them to the Camp Directors.
 Assist in the maintenance of the camp as needed. This means sweeping and mopping floors, wiping tables/counter
tops, putting supplies away, set up and break down of equipment, etc.
 Report to all camp events and meals on time.
 Abide by the midnight curfew. Unless otherwise directed.
B. PUBLIC RELATIONS
 Maintain a healthy relationship with all camp personnel. Attempt (with Senior Counselor) to correct any minor
(behavior) problems before they become serious problems.
 Act in a courteous and friendly manner when leading the group in camp. Maintain a non-abrasive relationship with
all other cabin groups.
C. PERSONAL DEVELOPMENT
 Be prepared to receive feedback and support from anyone at camp.
 Maintain a positive and open outlook. Try to work out problems with the rest of the staff. Be sensitive to other
staff member needs.
 Report and discuss all continuous problems and concerns with Senior Counselor and Camp Directors.
 Be a positive role model for the children. Reward and encourage their good behavior with attention and affection.
 Develop skills in planning and implementing activities with children.
POSITION TITLE:
SUPERVISOR:
Junior Counselor
Counselor in Assigned Cabin
GENERAL FUNCTION:
To participate under the supervision of the Counselor in planning or implementing activities. Activities are planned for 714 year olds in a camping program for children, carriers and siblings affected by bleeding disorders. To actively interact
with children while providing a positive young adult role model. To promote and encourage their individual growth.
SKILLS:
Applicant must be 16-17 years old (applicant must turn 16 years old by June 2015). Past work with children, including
siblings in a recreational or educational setting is desirable. Previous babysitting experience is a plus. An interest in
leadership skills and willingness to learn and understand organizational skills and group dynamics. Ability to and interest
to help professional staff lead a variety of recreational activities including: sports, games, creative arts and environmental
education, and to assist with the implementation of private HASDC camp activities as needed. Ability to perform under
stress/pressure while remaining flexible. Ability to recognize the importance of safety at all times. Genuine interest in
working with people a must.
JOB SEGMENTS:
A. PROGRAM DEVELOPMENT
 As part of a group, work with Counselors and professional staff to carry out recreational activities for 7-14 year
olds in a camping program.
 Stay with your assigned group at all times unless previous arrangements have been made with the Counselor.
 In leading activities, encourage kids to take responsibility (i.e., clean up after themselves, etc.)
 Follow all HASDC and program policies, as well as legal guidelines.
 Attend teen leadership camp and all staff training events.
 Report all accidents to the Counselor, who must report them to the Camp Directors.
 Assist in the maintenance of the camp as needed. This means sweeping and mopping floors, wiping
tables/counter tops, putting supplies away, set up and break down of equipment, etc.
 Report to all camp events and meals on time.
 Abide by the midnight curfew, unless otherwise directed.
B. PUBLIC RELATIONS
 Maintain a healthy relationship with all camp personnel. Attempt (with Counselor) to correct any minor
(behavior) problems before they become serious problems.
 Act in a courteous and friendly manner when leading the group in camp. Maintain a non-abrasive relationship
with all other cabin groups. Be a role model for the campers.
C. PERSONAL DEVELOPMENT
 Be prepared to receive feedback and support from anyone at camp.
 Maintain a positive and open outlook. Try to work out problems with the rest of the staff. Be sensitive to other
staff member needs.
 Report & discuss all continuous problems and concerns with Counselor and Camp Directors.
 Be a positive role model for the children. Reward and encourage their good behavior with attention and
affection.
 Develop skills in leadership as well as planning and implementing activities with children.
POSITION TITLE:
SUPERVISOR:
Counselor
Camp Directors
GENERAL FUNCTION:
To participate under the supervision of the Camp Directors in planning and implementing activities. Activities are planned
for 7-14 year olds in a camping program for children, carriers and siblings affected by bleeding disorders. To actively
interact with children while providing a positive adult role model. To promote and encourage their individual growth.
SKILLS:
Applicant must be at least 18 years old (as of June 2015) and completed at least two years in the Junior Counselor
program OR other camp experience. Past work with children in a recreational or educational setting is desirable. An
interest in leadership skills and willingness to learn and understand organizational skills and group dynamics. Ability and
interest to help professional staff lead a variety of recreational activities including: sports, games, creative arts and
environmental education, and to assist with the implementation of private HASDC camp activities as needed. Ability to
perform under stress and pressure while remaining flexible. Ability to recognize the paramount importance of safety at
all times. A genuine interest in working with people.
JOB SEGMENTS:
A. PROGRAM DEVELOPMENT
 As part of a group, help professional staff conduct recreational activities for 7-14 year olds in a camping program.
 Stay with your assigned group at all times unless previous arrangements have been made with the Camp
Directors.
 In leading activities, encourage children to take responsibility for themselves (i.e., clean up after themselves, etc.)
 Follow all HASDC and program policies, as well as legal guidelines.
 Attend all staff training events.
 Pass background check.
 Report all accidents to the Camp Directors.
 Assist in the maintenance of the camp as needed. This means sweeping and mopping floors, wiping
tables/counter tops, putting supplies away, set up/break down of equipment, etc.
 Report to all camp events and meals on time.
B. PUBLIC RELATIONS
 Maintain a healthy relationship with all camp personnel. Attempt (with Directors) to correct any minor behavior
problems before they become serious.
 Act in a courteous and friendly manner when leading the group in camp. Maintain a non-abrasive relationship
with all other cabin groups.
C. PERSONAL DEVELOPMENT
 Be prepared to receive feedback and support from anyone at camp.
 Maintain a positive and open outlook. Try to work out problems with the rest of the staff. Be sensitive to other
staff members’ needs.
 Report and discuss all continuous problems and concerns with Camp Directors.
 Be a positive role model for the children. Reward and encourage their good behavior with attention and
affection.
 Develop skills in leadership as well as planning and implementing activities with children.
POSITION TITLE:
SUPERVISOR:
General Volunteer
Camp Directors
GENERAL FUNTCION:
General volunteers are always needed to help with a variety of camp related activities. General volunteers are not
counselors, junior counselors or medical staff. They stay with other general staff in staff cabins. They are available, on
call, and as scheduled to relieve other staff and to back up counselors and junior counselors as well as to provide
additional camp assistance and event planning assistance with set-up, clean-up, and event production as needed.
POSITION TITLE:
SUPERVISOR:
Medical Staff
Camp Directors
GENERAL FUNCTION:
Medical Staff Volunteers are certified and registered doctors, physician assistants, nurses, physical therapists, social
workers, child life therapists, phlebotomists or other medically oriented team professionals. Medical staff are an
important component to the camp program. Medical staff report to the Camp Directors. Medical staff are requested to
arrive at camp on Sunday June 14th to prepare the med shack for camper arrivals, but may receive an exemption if they
have extensive camp experience or have worked extensively with the hemophilia population in the past.
POSITION TITLE:
SUPERVISOR:
Co-Director
HASDC Executive Director
GENERAL FUNCTION:
Please contact the HASDC office for further details.