Dear New Counselor Applicant:
Thank you for your interest in applying for a volunteer counselor position for Ronald
McDonald Camp 2014. The Ronald McDonald Camp offers children with cancer a chance
to enjoy an unforgettable summer camp experience. Our week-long sleep away camp
for boys and girls, ages 7 – 17, is specifically created for children who are currently
receiving treatment or who have completed treatment for cancer and their siblings. A
Leadership Training (LIT/CIT) program for young adults ages 18 and 19 also runs during
the same week.
We welcome volunteers of all backgrounds to share their passion, talent and time with
us. Counselors must be at least 20 years of age, in good health, energetic, flexible, fun
and responsive to the needs of children. Each new counselor volunteer agrees to the
following time commitment:
•
•
•
•
An interview after receipt of your application,
A full-day group interview and orientation in Philadelphia on a Saturday
or Sunday in June (TBA),
Approximately 3 hours of online training prior to camp
The full week of camp - August 16-23 (children will arrive on August 17).
I can guarantee that your contribution will be rewarded with memories that will last a
lifetime!
How to apply for a position as a R onald M cDonald Cam p Counselor
The Ronald McDonald Camp is fortunate to have a large ratio of returning counselors
each year. Even with our numerous dedicated and loyal counselors, a number of new
counselor positions open up each year. Please be assured that your request will be given
every consideration. To apply as a new Ronald McDonald Camp Counselor requires quite
a few forms. We hope you understand that this is necessary to ensure the health and
wellbeing of our special campers and yourself. Thank you for your attention to this
process. Please download and submit the following forms:
 Application
 Health Form – please note a physical completed within 24
months prior to attending Camp is required along with
immunization records and the date of your last tetanus shot
 TB Test form – all counselors are required to have TB test
done within 12 months of arriving at camp – if we do not
receive a negative test for TB from you, you will not be
allowed to come to camp. Because we have children with
depressed immune systems, we must ensure they are not
exposed to TB.
 Criminal background check. Please fill this form out completely
 References and Essay
 Application checklist (use as a guide, no need to submit)
Please read all instructions carefully and be sure to place your name on the bottom of
each submitted page. Only complete applications will be considered. Please send all
forms from the application packet by email or USmail (do not fax) by May 1,
2014 to:
Carolann Costa
Philadelphia Ronald McDonald House
100 E. Erie Ave
Philadelphia, PA 19134
If your physical is scheduled after May 1 due to insurance restrictions, please send in all
other forms by May 1 with a note giving us the date of your scheduled physical. We will
expect to receive your Physical Form immediately after your appointment.
Shortly after your application has been received, you will be contacted to set up an
interview. If you have any further questions, you may contact one of us below:
For general application questions:
Carolann Costa [email protected] 215-291-0907
For m edical questions only:
Anne Wohlschlaeger, CRNP [email protected]
215-590-3435
Please visit our website at www.philarmh.org/ronaldmcdonaldcamp for more information
and camp photos. Thank you for your interest in the Ronald McDonald Camp. We are
always very excited to welcome new counselors to our camp family!
Happy Camping!
Cindy Candela-Ryan
RMC Camp Director
The Ronald McDonald Camp is accredited by the American Camp Association (ACA)
Ronald McDonald Camp 2014
VOLUNTEER STAFF APPLICATION
CAMP DATES: AUGUST 16th-23rd
Mail or email all forms to the address below. Please do not fax .
Carolann Costa
Ronald McDonald Camp
100 E Erie Avenue/Philadelphia, PA 19134
[email protected]
ALL MATERIALS MUST BE RECEIVED BY MAY 1, 2014
Please check:
_____Returning Counselor
_____New Counselor Applicant
If returning, how many years have you been a counselor? (don’t include 2014) _________
Have you ever been a RMC camper? ___Yes ___No If yes, ___Patient or ___Sibling?
I. Personal Information:
Name _______________________________________________________________________________
Name as you would like it to appear on your camp name tag: ___________________________________
Age __________
DOB______/_______/_______
Home Address ________________________________________________________________________
_____________________________________________________________________________________
Home phone____________________________ Cell phone____________________________________
E-mail Address ______________________________________
If applicable, please indicate your school mailing address.
____________________________________________________________________________________
___________________________________ Effective Dates ____________________________________
II. Employment History (returning counselors please provide current employer only)
Current Company / Organization and Address
____________________________________________________________________________________
____________________________________________________________________________________
Position______________________________
Part Time____
Full Time____
Employment
Dates_______________ Supervisor____________________________ Phone_____________________
Previous Company / Organization and Address
____________________________________________________________________________
____________________________________________________________________________
Position______________________________
Part Time____
Full Time____
Employment
Dates_______________ Supervisor____________________________ Phone____________________
Page 2
III. Volunteer experience (returning counselors move to section IV)
1) Organization/Address ________________________________________________________
____________________________________________________________________________
Position______________________________________________________________________
Dates_______________ Supervisor_______________________________________________
Phone_________________________
2) Organization/Address ________________________________________________________
____________________________________________________________________________
Position______________________________________________________________________
Dates_______________ Supervisor_______________________________________________
Phone_________________________
IV. General Information
a. Staff T-Shirt Size: (circle gender & size) LADIES
b. How did you hear about RMC?
____ Newspaper
____ TV
____Radio
MENS
// S
____ RMC Volunteer
M
L
XL
2XL 3XL
____ Other
Referred by _______________________ Other: _____________________________________
c. Indicate the age group you would most like to work with, please number by order of preference,
we will do our best to accommodate your request:
____ 7-9
____ 10-12
____ 13-15 ____ 16-17
_____no preference
e. List below if you have any special interests that you would like to potentially teach or assist with
at camp. Indicate if you are certified:
____________________________________________________________________________
Application Essay: Please attach to application
New Counselors: What prompted you to apply to be a volunteer counselor at RMC? What would
you like to contribute by being a volunteer counselor?
*******************************************************************************************************
The information I have provided in this application packet is true and complete. I understand that by submitting this
application I hereby attest that I have no criminal record nor have a past history of child abuse as indicated by my
clearance checks. I understand that if I am selected as a volunteer, any false statements or references will be grounds
for immediate dismissal.
Signature ________________________________________ Date ____________________
Page 3
Ronald McDonald Camp 2014
Volunteer Staff Application
Our Mission Statement:
The mission of Ronald McDonald Camp is to provide a true overnight summer camp
experience for children being treated for cancer and their siblings, ages 7-17. Our
camper-centered program is designed to foster independence, friendship and group
belonging among campers who share a common experience with cancer. The
ultimate goal is to be a place where kids can enjoy being kids.
**********************************************************************************************************
Your voluntary time and dedication as a member of the Ronald McDonald Camp staff are greatly
appreciated. As we strive to attain and surpass our Mission Statement, it is critical that every staff
member is fully committed to the program and understands the expectations outlined in the
agreement below. Our foremost goal is to provide our campers with the best camp experience
possible in a safe environment. Your attention to and agreement with the items below will insure
that we are able to accomplish our goals.
**********************************************************************************************************
Counselor Agreement
1. I agree to remain at camp from the beginning of orientation until the final staff meeting on the
last day of camp. If unforeseen circumstances arise, (i.e. family emergency), I will discuss this with
the Camp Director so that the needs of the program will continue to be met.
2. I will not leave camp property during the camp session without consent of the Camp Director.
3. I will not use or bring alcohol, tobacco products or any illegal substances which are strictly
prohibited on camp property or during any sanctioned camp activities off camp property.
4. I agree to keep all prescription and other medications in the camp wellness center.
5. I understand that RMC cannot be responsible for my personal possessions and that I should not
bring valuable items to camp.
6. I understand that there is a 1:00am curfew. I agree to be inside my own cabin by this time each
night.
7. I agree to refrain from pranks or other activities, which divert time, attention and energy away
from the campers and camp program.
8. I understand that campers must always be supervised by an adult staff member. I agree to
never leave my campers unsupervised. I also understand that I should never be alone with one
camper in an area away from others’ sight in order to protect myself and our campers.
Page 4
9. I will maintain friendly and supportive relationships while at camp. I also agree to refrain from
any intimate, suggestive or sexual activities with anyone at camp.
10. I will be at all scheduled activities on time and prepared to fully participate.
11. I agree to use golf carts only if I am authorized to do so to transport campers or supplies. I will
drive golf carts safely and responsibly.
12. I will maintain appropriate and acceptable standards of dress and behavior while at camp as
listed in the staff manual.
13. I agree to respect the Timber Tops camp facility and its natural environment.
14. I understand that Leaders/Counselors in Training (LITS/CITS) are participating in a supervised
leadership training program. They are not considered nor do they have the responsibilities of camp
staff and may not be left with campers without a staff person present. I will respect and support
their training process and provide a role model of leadership.
15. I give permission to Ronald McDonald Camp to use photographs and video in which I may
appear for official purposes of advertisement and donor solicitation.
16. I will read the staff manual thoroughly prior to camp.
17. I agree to strictly follow RMC’s off-season contact, internet communication and photo policies.
I understand that failure to comply with any of the above terms could result in my being
asked to leave camp or not be eligible to return as a staff member in future years.
Print name___________________________________________________________________
Signature_______________________________________________
Date _______________
Page 5
Ronald McDonald Camp 2014
Internet Communication Policy
Off-season Contact
We recognize that the Internet, when used appropriately, provides many safe ways to stay in touch
and communicate with friends. We view Internet venues (MySpace, Facebook, Twitter, Instagram,
etc) as your right to self-expression and generally regard them in a positive light. Once you identify
yourself as a Ronald McDonald Camp employee/volunteer in a social networking profile, or any
Internet medium, however, we require you, as a condition of volunteering or employment at Camp,
to observe the guidelines listed below. Even if you do not intend to, and even if you state
otherwise, once you identify yourself as an employee or volunteer of Ronald McDonald Camp, you
must understand that anything you post or say on the site can then be seen as a reflection of
Camp. These guidelines have been established to assure that all staff, volunteers, campers and
families may enjoy an emotionally and physically safe environment.
For the purpose of Ronald McDonald Camp and these policies, the “off-season” is defined as the
day camp ends until the first day of camp the following year. The term “camper” is defined as
patients and siblings who attend camp (ages 7-17).
The “Ronald McDonald Camp Off-Season Contract,” is a document that outlines the particulars of
the Off-Season Contact and Internet Communication policies. Every volunteer staff member and
LIT/CIT will sign and agree to the terms of this contract and is made aware that a violation of any
portion of the contract is subject to immediate disciplinary action, including termination of current
and future involvement with Ronald McDonald Camp.
Contact outside of camp and during the off-season
For the purpose of Ronald McDonald Camp (RMC) and this policy, “contact” is defined as phone
calls, emails, instant messages, social gatherings, or any other communication/activities not
organized or sponsored by RMC. At the close of camp, communication with campers by RMC
summer staff and CITs is no longer authorized by the camp. RMC staff and CITs should not
initiate contact with individual campers in any way; in person, by phone, email, texting,
social media or instant messaging after the season. If you are contacted by a camper or have
reason to contact a camper, please contact the Camp Director at [email protected] so that
parental permission may be obtained. Exceptions to these policies are possible in situations where
Ronald McDonald volunteer staff members have had relationships with camper families prior to
becoming involved in Ronald McDonald Camp. In those instances, please contact Camp Director
to discuss.
Internet Communication
Communicating with campers using social networking websites like Facebook, Twitter, MySpace,
Instagram, etc. is prohibited unless parental permission is given to the Camp Director. Every effort
should be made on your part to keep social network profiles and blogs private. Staff and LIT/CIT
with social networking sites should not request to be friends with campers or approve friend
requests from campers unless parental consent is given. If you receive a friend request from a
camper and want to accept, please contact the Camp Director to be advised if parental
consent has been given. Staff and LIT/CIT can join the Philadelphia Ronald McDonald House’s
Facebook page.
Page 6
Ronald McDonald staff and LIT/CIT acknowledge that the following internet communication
activities are prohibited by Ronald McDonald Camp and therefore agree not to use a social
networking site, group page, personal website or other internet medium to:
•
•
•
•
•
•
•
•
•
•
•
Create a Ronald McDonald Camp “group page” or unofficial website.
Post digital pictures or videos of campers (see Digital Photograph Policy).
Post digital pictures of staff members without their prior permission.
Engage in online harassment, bullying or intimidation of RMC staff or campers.
Discuss conduct or behavior prohibited by camp policy.
Disparage the Ronald McDonald Camp name or its program, campers, families or other
volunteer staff associated with it.
Display inappropriate pictures or proof of involvement in illegal activities (i.e. drugs, underage drinking or hazing).
Post comments that are derogatory with regards to an individual’s race, gender, religion,
sexual orientation or disability.
Use disrespectful, obscene, vulgar, suggestive or sexually explicit language
Post comments on campers’ personal pages.
Discuss personal medical information relating to a volunteer staff member or camper.
Digital Photographs and Video
Parents or guardians of Ronald McDonald Camp campers who have given consent for their
children’s photographs to be taken, distributed, broadcast or publicized have done so ONLY by
and for the official use of Ronald McDonald Camp and the Philadelphia Ronald McDonald House.
The only photographs of campers that can be posted publicly or shared by volunteers and
staff are those on the PRMH Ronald McDonald Camp official website or official publications.
Photographs or video clips taken on a volunteer staff member’s personal digital camera at Ronald
McDonald Camp are considered their personal property. However, staff must adhere to the
following guidelines:
• Pictures or videos of campers cannot be emailed or posted on personal web pages or
on public photo-sharing websites (i.e. Facebook, Kodak Gallery, Snapfish, Shutterfly,
YouTube, Instagram)
• Any and all public use of campers’ pictures for activities or projects organized or
sponsored by Ronald McDonald Camp, such as staff recruitment or fundraising, must
be approved by the Camp Director prior to use.
If photos are found to be displayed on the Internet in any capacity without prior permission, the
person responsible will be contacted immediately to remove the pictures and disciplinary action will
be taken by Ronald McDonald Camp. We sincerely hope that you will respect our policies and help
us maintain the safety, privacy and security of our campers.
My signature on this contract indicates that I have carefully read and agree to abide by its terms
and conditions.
________________________________________________
(Signature)
___________________
(Date)
____________________________________________________
(Print name)
Page 7
Criminal History Background Report Authorization
By signing below, I knowingly and voluntarily authorize the Philadelphia Ronald McDonald House
(PRMH) to obtain a criminal history background report from a “consumer reporting agency”. I
understand I have rights under the FCRA, including the rights discussed in the FCRA Summary of
Rights, which has been provided to me along with this Authorization form. This Authorization shall
remain on file and serve as an ongoing authorization for the PRMH to obtain criminal history
background reports on me while I am employed/volunteering at the PRMH. I also acknowledge
receiving a written Summary of Rights under the FCRA along with this Criminal History
Background Report Authorization form.
_______________________________________ ___________________________________ Name (Signature) Date Signed __________________________________________________________________________________ Full Name (PLEASE PRINT) First, Middle, Last _________________________________________ _____________________________________ Social Security Number Date of Birth (Month, Day, Year)* _________________________________________ _____________________________________ Maiden Name (if applicable) Phone # _________________________________________ _______________ _____ ____________ Home Address City State Zip Code Please list County and State, other than above, for past 7 years: County__________ State______; County__________ State_______; County________ State_______ *Date of Birth required for background investigation purposes only, and will be used for no other purpose. Created: 12/2013
Revised: 1/2014
Page 8
Ronald McDonald Camp 2014
STAFF HEALTH FORM
Name _____________________________________ Date of Birth______________ Male___ Female___
Role at Camp: _____________________________________________________________________________
Address (if in school, please provide school and summer address):
_________________________________________________________________________________________
_________________________________________________________________________________________
Home Phone___________________ Work Phone___________________ Cell Phone ____________________
Email address _____________________________________________________________________________
Person to Contact in case of an emergency during the week of camp:
Name__________________________________________ Relationship to you ________________________
Day phone ___________________ Evening Phone _____________________ Cell _____________________
MEDICAL INFORMATION/HEALTH HISTORY
Name of Physician/Nurse Practitioner: __________________________________________________________
Address: _________________________________________________________________________________
Physician’s Phone ______________________________
Health insurance plan/carrier_________________________ Policy group number _______________________
**PLEASE ATTACH FRONT AND BACK COPY OF YOUR HEALTH INSURANCE CARD**
Do you have history of any of the following? (Check all that apply)
___Recent injury, illness, infectious disease
___Asthma ___Ear infections ___High blood pressure ___Seizures
___Diabetes ___Heart disease ___Blood disorder ___Arthritis ___Depression ___Headaches ___Eating disorder
___Emotional difficulties for which you sought professional help ___Surgery ___ Cancer
Please explain all that are checked (include dates): _________________________________________________
__________________________________________________________________________________________
If any of the above issues are active, please complete the following:
Physician/NP ______________________________________ Specialty Area ____________________________
Address ______________________________________________________ Phone________________________
Other physical disorders and conditions (include prosthesis, wheelchairs, etc):
List any restrictions or limitations for camp activities:
Additional information for health care staff at camp:
Page 9
Ronald McDonald Camp 2014
STAFF HEALTH FORM
MEDICATION INFORMATION
- Your medication MUST be kept at the Wellness Center; this is to ensure that medication is kept
out of reach of the campers. You can access your meds and take them yourself in the wellness
center except during camper meds time.
- Bring enough medication to last entire time at camp.
- Keep your medications in the original packaging/bottle that identifies prescribing physician (if a
prescription drug). It must also have the name of the medication, dosage and frequency of
administration.
- Write your name on the bottle and let medical staff know if any meds impair your ability to
perform your job responsibilities at camp.
Over-The-Counter Medications Available At Camp
Acetaminophen (Tylenol); Ibuprofen (Advil/Motrin); Diphenhydramine (Benadryl);
Pseudoephedrine (Sudafed); Zyrtec; TUMS; Stool softeners.
_______ I do not currently take any medications.
Please List All Medication You Take On A Regular Basis
Drug
Dosage
Frequency
Reason For Taking
ALLERGIES: LIST ALL KNOWN
Medication Allergy
Reaction
Management
Food Allergy
Reaction
Management
Other- insect stings, hay fever, asthma, animal etc.
Management
_______ I have no known allergies.
Any medically prescribed meal plan or dietary restrictions. ______________________________
Staff Name: (please print) ______________________________________________________
Page 10
Ronald McDonald Camp 2014
STAFF HEALTH FORM
Which of the following illnesses have you had?
Measles
Hepatitis B
Chicken Pox
Hepatitis A
German Measles
Hepatitis C
Mumps
HIV
IMMUNIZATION HISTORY
**You must provide dates or copy of immunization record (New applicants, if you do not
have this information you must provide vaccine titers)**
_____ My immunizations are on file with Ronald McDonald Camp (check if yes)
Please completely fill in immunization record below or attach a copy
Immunization
Dates of Immunizations
DTP
Polio
MMR
Hepatitis B
Varicella
H. Influenza B
(HIB)
Date of last Tetanus booster ____________ (Should be given every 10 years)
List any recent exposure to infectious/communicable diseases (i.e., chicken pox)
___________________________________________________________________
_______________________________________________________________
Staff name (please print): ______________________________________________
Page 11
Ronald McDonald Camp 2014
STAFF HEALTH FORM
AGREEMENT STATEMENT
In signing this form, I confirm that the information contained herein is complete and true. I give
permission for Camp Medical Staff to administer any routine and/or emergency first-aid. I
understand that every effort will be made to contact named emergency person, but in the event
that they cannot be reached, I hereby give permission to Camp Medical Staff to hospitalize and
secure proper medical treatment as needed.
X ___________________________________________________ ___________________
Signature of applicant
Date
AUTHORIZATION AND RELEASE
I _________________________________________ , hereby waive and release the Philadelphia
Ronald McDonald House, the Children's Hospital of Philadelphia, and any co-sponsoring
organizations from liability for injuries, damage, or loss of personal property.
X ___________________________________________________ ____________________
Signature of applicant
Date
PHOTO RELEASE
I give permission for use of video and/or voice tape, and/or photographs in which a likeness or
representation of me may appear for Ronald McDonald Camp promotions.
X ___________________________________________________ ____________________
Signature of applicant
***ATTACH FRONT AND BACK COPY OF HEALTH INSURANCE CARD***
Don’t forget to include your completed TB Test form
Return Completed Forms To:
Carolann Costa
Ronald McDonald Camp
100 East Erie Avenue,
Philadelphia, PA 19134
Staff Name (Please print): _____________________________________________________
Page 12
Ronald McDonald Camp 2014
STAFF PHYSICAL EXAM
Applicant’s Name___________________________________________
A PHYSICAL MUST BE COMPLETED WITHIN 24 MONTHS OF ATTENDING CAMP AND THIS
FORM IN ITS ENTIRETY SHOULD BE REVIEWED BY YOUR PHYSICIAN AND SIGNED
Date of physical exam___________
Ht_____ Wt_____ BP_____ Pulse______ Respiration______
Abnormal findings: ___________________________________________________________________
Activity restrictions (e.g. strenuous exercise, swimming, heavy lifting, etc):
__________________________________________________________________________________
I have reviewed this applicant's health history, immunization record and performed a physical
examination. I recommend this person for a volunteer position at a one-week overnight camp
program and believe he/she is capable of engaging in all camp activities except as noted above.
Physician's/Nurse Practitioner’s Signature_____________________________________________
Date________________________
Office Location ________________________________________________________________
____________________________________________________________________________
Office Stamp:
Return completed form to:
Carolann Costa, Ronald McDonald Camp, 100 East Erie Avenue, Philadelphia, PA 19134
Page 13
Ronald McDonald Camp 2014
STAFF TB Mantoux FORM
TB Mantoux Test
Tuberculosis (TB) is a bacterial infection that is most often found in the lungs but can spread to
other parts of the body. TB in the lungs is easily spread to other people through coughing or
laughing. Many of our camper’s immune systems are not functioning 100% due to their disease or
treatment. Because of this we MUST make every effort to protect them from contracting any kind
of sickness while at camp.
You MUST have a negative TB Mantoux test PRIOR to coming to camp.
*If we do not have a copy of your test you may NOT come to camp*
This test must be completed EVERY year by ALL camp staff.
If you had a TB test completed prior to receiving this application/form request a copy of your
results from the facility where the test was taken and attach it to this form. Once completed you
may send this form to:
Carolann Costa
Ronald McDonald Camp
100 E. Erie Avenue
Philadelphia, PA 19134
Fax: (215) 291 0895
Typical procedure for TB Skin Test (this is sometimes referred to as PPD Test):
1. Make an appointment with your doctor requesting a TB Skin Test.
2. At the appointment a small needle will be used to inject some test material called tuberculin
under the skin of your arm. You CANNOT get TB from this test material.
3. In 2 or 3 days you will have to return to have a health care worker look at your arm for the
result.
4. Please have the healthcare worker complete the information below.
*************************************************************************************************************
RESULTS FOR _____________________________________ (PLEASE PRINT PATIENT’S NAME)
Date of TB Mantoux Test __________________
Negative ________ Positive ______
Signature of Healthcare worker: ___________________________________
Date: ________
Healthcare worker (please print name): _____________________________________________
Page 14
Ronald McDonald Camp 2014
New Staff Application Checklist
Did you complete the following?
□ APPLICATION
o Does it have your updated address and EMAIL?
o Have you read and signed the counselor agreement?
o Have you read and signed the off-season contact and internet policy?
□ ESSAY (on separate sheet of paper)
□ 3 REFERENCES
□ HEALTH FORM
o Did you include your immunization records?(must include dates) or copies of
titers
o The date of your last TETANUS shot? (due every 10 years)
o Photocopy of your Drivers License and Health Insurance Card
□ PHYSICAL FORM
o Have you had a physical? (needed within 24 months of attending camp)
o Is the form signed by a medical professional?
□ TB TEST FORM
o You cannot come to camp without this form complete and signed by a medical
professional prior to camp (Please notify Anne Wohlschlaeger if you have had
a positive TB test in the past)
□ BACKGROUND CHECK RELEASE FORM o Form must be completely filled out □ Does every page of each document have your name on it?
Thank you for taking the time to send in a complete
application! J
Ronald McDonald Camp 2014
CAMP COUNSELOR REFERENCE
_________________________ is applying for a volunteer position at Ronald McDonald Oncology
Camp, a weeklong overnight camping experience for children (7-17yrs) who have or had cancer.
Volunteers are responsible for the safety, happiness and well being of a group of campers. Please
complete this form honestly to help us determine if this prospective staff member will be a positive
role model for young people. Please note we may contact you in case some follow up information
is desired.
Name___________________________________
Phone #____________________
Address_________________________________________________________________
Relationship to applicant? _______________________________ For how long? ________
Please rate the applicant in the following areas using a 0-3 scale
(0 = poor, 1 = fair, 2 = average, 3 =above average, U = cannot evaluate):
____ Ability to work with others
____ Communication Skills
____ Ability to work with children
____ Ability to handle change
____ Listening skills
____ Supervision skills
____ Ability to seek & accept supervision
____ Ability to live with children 24/7
____ Judgment / common sense
____ Punctuality
____ Patience
____ Ability to work with adults
Knowing that we do not expect any applicant to be outstanding in all areas, please honestly assess
this applicant using the following statements:
Strongly Agree - Agree - Neutral - Disagree - Strongly Disagree
Applicant has a positive self-image _________________________________
Applicant is a leader _____________________________________________
Applicant follows directions well ____________________________________
Applicant is self-motivated ________________________________________
Applicant thinks up new ideas _____________________________________
Would you feel comfortable having your child in this person’s care for one week?
___Yes ___ No
Realizing we all have areas in which we can improve, in your opinion, in what areas does the
applicant exhibit limits or weaknesses?
________________________________________________________________________
General Comments: Please feel free to add comments on back or on a separate sheet of paper
Signature___________________________________________ Date _________________
Please send to: Carolann Costa, Ronald McDonald Camp, 100 East Erie Avenue Philadelphia, PA 19134
Phone: 215 291 0907
Ronald McDonald Camp 2014
CAMP COUNSELOR REFERENCE
_________________________ is applying for a volunteer position at Ronald McDonald Oncology
Camp, a weeklong overnight camping experience for children (7-17yrs) who have or had cancer.
Volunteers are responsible for the safety, happiness and well being of a group of campers. Please
complete this form honestly to help us determine if this prospective staff member will be a positive
role model for young people. Please note we may contact you in case some follow up information
is desired.
Name___________________________________
Phone #____________________
Address_________________________________________________________________
Relationship to applicant? _______________________________ For how long? ________
Please rate the applicant in the following areas using a 0-3 scale
(0 = poor, 1 = fair, 2 = average, 3 =above average, U = cannot evaluate):
____ Ability to work with others
____ Communication Skills
____ Ability to work with children
____ Ability to handle change
____ Listening skills
____ Supervision skills
____ Ability to seek & accept supervision
____ Ability to live with children
____ Judgment / common sense
____ Punctuality
____ Patience
____ Ability to work with adults
Knowing that we do not expect any applicant to be outstanding in all areas, please honestly assess
this applicant using the following statements:
Strongly Agree - Agree - Neutral - Disagree - Strongly Disagree
Applicant has a positive self-image _________________________________
Applicant is a leader _____________________________________________
Applicant follows directions well ____________________________________
Applicant is self-motivated ________________________________________
Applicant thinks up new ideas _____________________________________
Would you feel comfortable having your child in this person’s care for one week?
___Yes ___ No
Realizing we all have areas in which we can improve, in your opinion, in what areas does the
applicant exhibit limits or weaknesses?
________________________________________________________________________
General Comments: Please feel free to add comments on back or on a separate sheet of paper.
Signature___________________________________________ Date _________________
Please send to: Carolann Costa, Ronald McDonald Camp, 100 East Erie Avenue Philadelphia, PA 19134
Phone: 215 291 0907
Ronald McDonald Camp 2014
CAMP COUNSELOR REFERENCE
_________________________ is applying for a volunteer position at Ronald McDonald Oncology
Camp, a weeklong overnight camping experience for children (7-17yrs) who have or had cancer.
Volunteers are responsible for the safety, happiness and well being of a group of campers. Please
complete this form honestly to help us determine if this prospective staff member will be a positive
role model for young people. Please note we may contact you in case some follow up information
is desired.
Name___________________________________
Phone #____________________
Address_________________________________________________________________
Relationship to applicant? _______________________________ For how long? ________
Please rate the applicant in the following areas using a 0-3 scale
(0 = poor, 1 = fair, 2 = average, 3 =above average, U = cannot evaluate):
____ Ability to work with others
____ Communication Skills
____ Ability to work with children
____ Ability to handle change
____ Listening skills
____ Supervision skills
____ Ability to seek & accept supervision
____ Ability to live with children
____ Judgment / common sense
____ Punctuality
____ Patience
____ Ability to work with adults
Knowing that we do not expect any applicant to be outstanding in all areas, please honestly assess
this applicant using the following statements:
Strongly Agree - Agree - Neutral - Disagree - Strongly Disagree
Applicant has a positive self-image _________________________________
Applicant is a leader _____________________________________________
Applicant follows directions well ____________________________________
Applicant is self-motivated ________________________________________
Applicant thinks up new ideas _____________________________________
Would you feel comfortable having your child in this person’s care for one week?
___Yes ___ No
Realizing we all have areas in which we can improve, in your opinion, in what areas does the
applicant exhibit limits or weaknesses?
________________________________________________________________________
General Comments: Please feel free to add comments on back or on a separate sheet of paper.
Signature___________________________________________ Date _________________
Please send to: Carolann Costa, Ronald McDonald Camp, 100 East Erie Avenue Philadelphia, PA 19134
Phone: 215 291 0907