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CAMPMED COUNSELOR APPLICATION Dear Prospective Counselor

VIEWS: 13 PAGES: 9

  • pg 1
									Dear Prospective Counselor,

Thank you for you interest in volunteering for CampMed at UCI. We appreciate the time you are
taking out of your busy schedule to learn more about our organization.

CampMed at UCI is a 501 (c)(3) non-profit organization founded in 1997 by medical and
undergraduate students. They saw the need for a local program that would target socio-economically
disadvantaged high school students interested in pursuing higher education specifically in the health
science fiends. Through the program we strive to provide an opportunity for high school students
faced with socioeconomic barriers to read beyond what they normally see and receive in their home
environments and gain inspiration from undergraduate students, medical students, graduate students
and medical professionals. CampMed is not only designed to expose the students to various health
professionals, it also aims to assist them in further developing their skills and accessing the resources
necessary to achieve their goals.

Ensuring the safety and well-being of our campers is CampMed’s number one priority. Keeping that in
mind, we ask for you to carefully complete the required paperwork by the deadline below.

Thank you for taking the first step towards becoming a CampMed volunteer. We truly appreciate you
interest in serving these students.

Please contact our directors, Paideia Le (ple@uci.edu) Jasmin Tanaja (jasmin.tanaja@gmail.com ),
or Roula Saleem (rsaleem@uci.edu ) should you have any questions regarding the application
process. You may also visit www.campmed.org to learn more about our organization


Applications need to be received by 3PM Friday, February 27th. Please turn into the CampMed
at UCI mailbox at the Office of the Dean of Students or send your application to:

CampMed at UCI
c/o University of California, Irvine
Office of the Dean of Students
Irvine, CA 92697-5125

Best regards,
CampMed Staff




                              CampMed at UCI · c/o University of California, Irvine            Page 1 of 9
                             Office of the Dean of Students · Irvine, CA 92697-5125
                                      Tel: (714) 615-1419 or (661) 373-8732
                                                www.campmed.org
                               Volunteer Counselor Job Description
                                   PLEASE READ CAREFULLY
Minimum Qualifications:
    Desire and ability to work with high school students in the outdoors. Prior experience working
     with students beneficial.
    Have no hesitation about becoming a mentor with the campers for at least one-year.
    Ability to relate to one’s peer group and work well with people from diverse backgrounds.
    Ability to accept supervision, guidance and constructive feedback.
    Ability to assist in teaching an activity.
    A positive role model for children and peers (exemplary character, good judgment,
     approachable, etc…)
    Reside in the Orange/Los Angeles County throughout May of 2009 to May of 2010
    Be a UCI Student
    Be at least 18 years old.

Major Responsibilities:
   Maintain the health and safety of all campers.
   Work closely with co-counselors to identify and meet camper needs.
   Create group unity and provide opportunities for each camper to experience success.
   Provide guidance and encouragement for the camper participation in activities.
   Assist coordinators in fundraising events from March of 2009 to March of 2010
   Keep in contact with mentee at a minimum of twice a month.
   Attend CampMed Mentorship events during the 2009-2010 academic years.

Benefits:
   Personal growth and satisfaction.
   Develop sustained friendships with people from diverse backgrounds who share a common
      goal of wanting to make a positive impact on the lives of the students.
   Opportunity to enhance interpersonal communication and leadership skills.
   Networking and connecting with professionals from the university, CampMed Staff, UCI
      medical students, medical professionals and UCI Medical center staff.

Mandatory Dates:
                                                           th
      CampMed Counselor Training: Sunday, April 19 . Time: TBA (minimum four hours)
                                                 st                           rd
      Annual CampMed: 10AM Friday, May 1 to 3PM Sunday, May 3
         **All participants must be transported by bus to campsite on Friday and back to campus on
         Sunday

          I hereby agree that I have read and understand the above. I do not have any limitations
          that would hinder my ability to safely perform any of the duties or essential functions of a
          CampMed volunteer counselor.
                                              Initial______________


                             CampMed at UCI · c/o University of California, Irvine           Page 2 of 9
                            Office of the Dean of Students · Irvine, CA 92697-5125
                                     Tel: (714) 615-1419 or (661) 373-8732
                                               www.campmed.org
                                     COUNSELOR APPLICATION
                                      Please Print or Type Clearly

Last Name __________________________ First Name ______________________________
Street Address ________________________________________________________________
City, State, ZIP ________________________________________________________________
E-mail _______________________________________________________________________
Pager/Cell ______________________________________

Gender (check ONE):   □ male □ female
Type of Student (check ONE): □ Undergrad □ Medical □ Grad

                             □ Post-Bac □ Other ___________________
Year (check ONE): □ first □ second □ third □ fourth □ fifth +

T-shirt size (check ONE): □ small □ medium □ large □ large □ x-large

Have you participated in CampMed before? (Check ONE): □ NO □ YES Year? _________
Do you have any special food allergies or special food needs? (vegetarian, vegan, etc…)
________________________________________________________

What mentoring/teaching experiences have you had within the past 4 years? Include nature of activity

Dates                Activity                                      Description

___________           _______________________                      ________________________________

                                                                   ________________________________

___________           _______________________                      ________________________________

                                                                   ________________________________

___________           ________________________                     ________________________________

                                                                   ________________________________

Describe activities that you have done within the past 4 years which promote cultural diversity.
Include the dates and a description of the nature of your involvement

Dates                Activity                                      Description

__________           _______________________                       ________________________________

__________          _______________________                        ________________________________
                             CampMed at UCI · c/o University of California, Irvine            Page 3 of 9
                            Office of the Dean of Students · Irvine, CA 92697-5125
                                     Tel: (714) 615-1419 or (661) 373-8732
                                               www.campmed.org
                                    COUNSELOR APPLICATION

Last Name __________________________ First Name________________________________

PERSONAL STATEMENT: (Considering that there are many other qualified applications, please
describe for the application committee what makes you different from the other applicants and why
you should be selected to be a counselor for CampMed.) **Optional: attach a separate, typed
page**




                            CampMed at UCI · c/o University of California, Irvine         Page 4 of 9
                           Office of the Dean of Students · Irvine, CA 92697-5125
                                    Tel: (714) 615-1419 or (661) 373-8732
                                              www.campmed.org
                               Nondiscrimination Policy Statement for
                                      University of California

The University of California, in accordance with applicable Federal and State law and University
policy, does not discriminate on the bases of race, color, national origin, religion, sex, disability, age,
medical condition (cancer-related), ancestry, marital status, citizenship, sexual orientation or status as
a Vietnam-Era veteran or special disabled veteran. The University also prohibits sexual harassment.
This non-discrimination policy covers admissions, access and treatment in University programs and
activities

                                           State Privacy Policy

The State of California Information Practices Act of 1977 (effective July 1, 1978) requires the
University to provide the following information to individuals who are asked to supply information
about themselves:

       The principal purpose for requesting the information on this form is to process
       application for admission and statistical analysis. State and/or Federal statute and/or
       University policy authorize maintenance of this information.

       Furnishing all (or specifically designated) information requested on this form is mandatory
       failure to provide such information will delay or may even prevent completion of the action for
       which the form is being filled out. Information furnished on this form may be used by the
       University for statistical analysis, and will be transmitted to the State and Federal governments
       as required by law

       Individuals have the right to review their own records in accordance with University personnel
       policy and collective bargaining agreements. Information applicable policies and agreements
       can be obtained from campus, laboratory or office of the President staff and Academic
       Personnel Offices.




                              CampMed at UCI · c/o University of California, Irvine              Page 5 of 9
                             Office of the Dean of Students · Irvine, CA 92697-5125
                                      Tel: (714) 615-1419 or (661) 373-8732
                                                www.campmed.org
                        COUNSELOR EMERGENCY INFORMATION
                Please provide requested information as completely as possible

GENERAL INFORMATION
Last Name _________________________ First Name, Middle ________________________

Street Address ________________________________________________________________

City, State, Zip _________________________________________________________________

Pager/Cell ________________________________

Age __________________ Birth date (i.e. MM-DD-YYYY) _____________________________

EMERGENCY INFORMATION

(1) Parent’s/Legal Guardian’s Name ________________________________________

Phone ________________________________ Relationship __________________

(2) Another Contact Person _________________________________________________

Phone ________________________________ Relationship ____________________

(3) Physician’s Name _____________________________________________________

Phone _______________________________ Hospital/Clinic ___________________

MEDICAL & DISABILITY INFORMATION

Please list current medical conditions and medications
________________________________________________________________________

Please list disabilities or concerns that may affect participation
_________________________________________________________________________

Please list any prescription medicine you are currently taking
_________________________________________________________________________




                         CampMed at UCI · c/o University of California, Irvine   Page 6 of 9
                        Office of the Dean of Students · Irvine, CA 92697-5125
                                 Tel: (714) 615-1419 or (661) 373-8732
                                           www.campmed.org
                                                             Participants Name: __________________________
                                                                                                         Please Print
                                 UNIVERSITY OF CALIFORNIA AT IRVINE
                                   Student Initiated Academic Preparation
                                                 “CAMPMED”
                    Waiver of Liability, Assumption of Risk, and Indemnity Agreement

Waiver: In consideration of being permitted to participate in any way in the UCI CampMed and its activities
including but not limited to the acid lake and suturing workshops, hereinafter the “UCI CAMPMED” event, I, for
myself, my heirs, personal representatives or assigns, do hereby release, waive, discharge, and covenant
not to sue The Regents of the University of California, its officers, employees, and agents from liability from
any and all claims including the negligence of The Regents of the University of California, its officers,
employees and agents, resulting in personal injury, accidents of illnesses (including death), and property loss
arising from, but not limited to, participation in “UCI CAMPMED.”

_______________________________________                _______________________________________
Signature of Parent (if 18 and under) Date           Signature of Participant            Date

Assumption of Risks: Participation in “UCI CAMPMED” carries with it certain inherent risks that cannot be
eliminated regardless of the care taken to avoid injuries. The specific risks vary from one activity to another,
but the risks range from 1) minor injuries such as scratches, cuts, puncture wounds, bruises, and sprains to 2)
major injuries such as eye injury or loss of sight, joint or back injuries, infections, heart attacks and
concussions to 3) catastrophic injuries including paralysis and death.

        I have read the previous paragraphs and I know, understand, and appreciate these and other
risks that are inherent in “UCI CAMPMED.” I hereby assert that my participation is voluntary and that I
knowingly assume all such risks.

Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD The Regents of the University
of California HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages and
liabilities, including attorney’s fees brought as a result of my involvement in “UCI CAMPMED” and to reimburse
them for any such expenses incurred.

Severability: The undersigned further expressly agrees that the foregoing waiver and assumption of risks
agreement is intended to be as broad and inclusive as is permitted by the law of the State of California and that
if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal
force and effect.

Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk, and indemnity
agreement, fully understand its terms, and understand that I am giving up substantial rights, including my
right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my
signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.

_______________________________________ _______________________________________
Signature of Parent (if 18 and under) Date Signature of Participant Date

Participants Age (if under 18) _______________



                                CampMed at UCI · c/o University of California, Irvine                    Page 7 of 9
                               Office of the Dean of Students · Irvine, CA 92697-5125
                                        Tel: (714) 615-1419 or (661) 373-8732
                                                  www.campmed.org
                                              UC Irvine CampMed
                                            MEDICAL INFORMATION
_________________________________             _____________________________                         ___________
Student Name                                  School                                                Grade

Is the student:        allergic to any medication/drug:        YES (    )      NO (      )
                       currently taking medication?            YES (    )      NO (      )
                       Any existing medical problems?          YES (    )      NO (      )


IF ANY ANSWER ABOVE WAS YES, PLEASE EXPLAIN
_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Insurance Carrier/Policy # _________________________________________


If I the parent/legal guardian am unable to be reached, please call

 ______________________________________________________
(Name)

_________________________                     ______________________________________
(Relation to student)                         (Primary and Secondary Telephone Numbers)

PERMISSION FOR EMERGENCY TREATMENT:
I understand that the Campmed staff will try to contact the parent in case of illness or injury. In case of illness or
injury, and when in the judgment of the staff, emergency medical attention is warranted, I authorize the staff to
seek medical attention. If deemed necessary, I give permission for my child to be taken by the Paramedics or
ambulance to a hospital, and for the doctor there to take whatever action is necessary to meet the emergency. I
understand that I am responsible for any charges incurred.


___________________________________                             _______________
(Parent / Legal Guardian Signature)                            (Date)


Parent/Legal Guardian Contact Information:

 _____________________________________                  ________________________________________
(Name of Parent/Legal Guardian)                        (Primary and Secondary Telephone Numbers)




                                 CampMed at UCI · c/o University of California, Irvine                   Page 8 of 9
                                Office of the Dean of Students · Irvine, CA 92697-5125
                                         Tel: (714) 615-1419 or (661) 373-8732
                                                   www.campmed.org
                                         MEDIA RELEASE FORM


The undersigned hereby authorizes the Regents of the University of California and their
appointed agents to photograph, videotape, audio record, televise, duplicate, and/or transfer to any
present or future technology

______________________________________ while a participant in the UC Irvine CAMPMED and
(Name of Participant, PLEASE PRINT)

agrees that the Regents of the University of California, its authorized agents, employees and
assignees may use the photographs, videotapes, and/or audio recordings prepared therefrom, to
reproduce, exhibit, publish, or distribute in such a manner as they deem fit. No compensation will be
paid for this use.


__________________________________                   ________________________
(Signature of Participant)                           (Date)


__________________________________                   ________________________
 (Witness)                                           (Date)

                                                     _________________________________

                                                     _________________________________
                                                     (Address of Participant)


If the participant is a minor, complete the following: I hereby approve the foregoing authorization.


__________________________________ _____________________
(Parent Signature) (Relationship)



_____________________________________

_____________________________________
(Address of Parent)




                               CampMed at UCI · c/o University of California, Irvine          Page 9 of 9
                              Office of the Dean of Students · Irvine, CA 92697-5125
                                       Tel: (714) 615-1419 or (661) 373-8732
                                                 www.campmed.org

								
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