Volunteer / Buddy Application

Contact Information

First Name:

Last Name:

Address:

City:

State: Select State Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennesse Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

Home Phone:

Cell Phone:

Applicant's Email:

Age:

Sex: Select Male Female

Birthdate:

Date of your injury:

T-shirt Size: Select S - Male M - Male L - Male XL - Male XXL - Male S - Female M - Female L - Female XL - Female XXL - Female

As a prospective volunteer, please give a short description of yourself. Tell us about your interests, your background, and why you want to volunteer for the Outdoor Adventure Challenge Programs for the Winter-Summer 2010.

Volunteering could possibly help with your field work credits!!!!

Emergency Contacts

Please be sure these people will be available during the week of camp.

Emergency Contact One

First Name:

Last Name:

Address 1:

Address 2:

City:

State: Select State Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennesse Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

Contact Number:

Relationship:

Emergency Contact Two

First Name:

Last Name:

Address 1:

Address 2:

City:

State: Select State Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennesse Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

Contact Number:

Relationship:

Additional Information

Medical Power of Attorney:    Yes No

Phone:

Current Physician:

Medical Insurance:    Yes No

Mobility

Do you have balance concerns:    Yes No

Do you have walking concerns:    Yes No

Require assistance on rough, uneven terrain:    Yes No

How far can you walk:   

Climb up and down stairs independently:    Yes No

Seizures

Seizures:    Yes No

Speech Concerns

Speech Concerns:    Select Normal Mildly Affected Moderately Affected

Hearing

Select Normal Hard of Hearing Wears Hearing Aid Sensitive to 'excessive' noise Extremely sensitive

Vision

Vision:    Select Normal No Peripheral Vision Wears Glasses Contacts

Don't forget your sunglasses.

Vitals

Heart Problems:    Yes No

Heart Murmer:    Yes No

Irregular Heart Beat:    Yes No

Blood Pressure Concerns:    Yes No

Experienced problems at Higher Elevation:    Yes No

Behavior

Memory:    Select It's Ok Mild Short-Term Loss Severe Short-Term Loss Extreme STM Loss

In a New Situation do you:    Select Get Lost Lose Belongings Run Away Wonder Off

Anger Issues:    Select None Mild Sometimes Severe Often

What Causes it?:   

What helps to calm you down:   

Frustration:    Select Never Sometimes Occasionally Often

Cause:   

Depression:    Select Never Sometimes Occasionally Always

Controlled by meds:   

Paranoia:    Select Never Sometimes Occasionally Always

Controlled by meds:   

Fears:   

Do you ever lose verbal contol:    Yes No

Do you ever lose physical contol:    Yes No

Are you currently receiving Psychotherapy:    Yes No

Back Problems

Do you now or have you ever had back problems? Have you ever injured you back?:    Yes No

If you answered yes to either of the 2 back related questions above, please describe your injuries:   

If you have ever received medical treatment for a back injury, please describe:   

Sleep Routine

Do you require a nap:    Select Never Sometimes Once a day Only when very active I rest only

Do you feel fatigued:    Select Feel Fine Not Usually Sometimes Only Occasionally Severely-all the time

Do you have trouble sleeping:    Select No Yes If it is noisy I need a light on I need total darkness In a new place

When do you usually wake up:   

When do you usually go to bed:   

Special routine:   

Eating

Eating or swallowing concerns:   

Dietary Concerns

Dietary needs:    (you must supply any special needs)

Allergies:    Yes No

Dislikes:    Yes No

Religious dietary needs:    Yes No

Vegetarian:    Yes No

Medication & Health Record

Medication:   

Taken for:   

how taken:   

as of (todays date):   

Medication:   

Taken for:   

how taken:   

as of (todays date):   

Medication:   

Taken for:   

how taken:   

as of (todays date):   

Medication:   

Taken for:   

how taken:   

as of (todays date):   

Over the counter ANYTHING:   

Doses:   

Vitamins and Herbs:   

Doses:   

*Should your medications change before camp-it is your responsibility to let us know!!!

What are you doing when you're not at camp?

Where do you live:    Select Own Home With Family Apt. Alone Group Home Apt with Roomate Assisted Living Facility

Are you in school:    Yes No

How do you get around:    Select Walk Bike Drive Bus Special Transit Arranged Rides Wheelchair

Where are you employed:   

Some FUN Questions

Do you sing:    Yes No

Do you play an instrument:    Yes No

If so, feel free to bring it to camp this year!!

Do you like jokes:    Select I like to hear them I like to tell them

Do you like stories:    Select I like to hear them I like to tell them

Your favorite activity/Hobbies Inside:   

Your favorite activity/Hobbies Outside:   

Who is your HERO and why:   

Character References

Please provide 2 character references. (Required information for acceptance)

Name:   

Relationship:   

Phone:   

Name:   

Relationship:   

Phone:   

Camp Questions

I am applying for:    Select April Fools Winter Happening Easter Seals BOEC Canoe Trip Creative Minds

Years I have attended Easter Seals:   

Years I have attended BOEC - Outdoor Adventure Challenge:   

Years I have attended BOEC - Canoe:   

Years I have attended BOEC - Creative Minds:   

Camps I have attended:   

How many years:   

Agreement, Consent & Release

With the understanding that the Easter Seal's Camp Summit and the Breckenridge Outdoor Education Center will make every reasonable effort to prevent accidents, injuries or other mishaps, I acknowledge the following

The undersigned gives The Brain Injury Alliance of Colorado (BIAC) permission to verify any information on this application for attendance at a camp sponsored by the BIAC (camp) and to contact references, case managers, and emergency contacts for any further information which may be necessary. The undersigned agrees to indemnify and hold harmless the BIAC for any and all claims, demands, costs, expenses, including reasonable attorney's fees, that the BIAC may suffer as a result of any claim, action, demand or judgment against it arising from the attendance at camp by this applicant. Provided, however, that the above and foregoing shall not be construed to indemnify the BIAC from any act of negligence or fault on the part of the BIAC, its officers, agents or employees. The undersigned does _____ or does not ______consent to having photograph(s) or video(s)taken of the named applicant during the camp period, and to said photograph(s) and video(s) being published in newspapers, magazines, television, publicity releases and/or other media. The undersigned, in case of an emergency involving the applicant and in the event the designated emergency contact cannot be reached by telephone, does hereby give permission for medical treatment which is necessary or desirable in the absolute discretion of any camp registered nurse or interns who possess a medical background. This medical care shall include, but is not limited to, examinations, treatments, immunizations, injections, anesthesia, surgery and other procedures, etc. The undersigned does hereby agree to allow the applicant to participate in all camp activities (except those specifically restricted). The undersigned gives permission for the applicant to ride in vehicles operated or leased by the BIAC, Easter Seals or Breckenridge Outdoor Education Center. The undersigned recognizes the right of the Camp Director, or the BIAC Lead, in his/her discretion, to terminate a camper or volunteer's stay at any time due to disciplinary or medical actions which might jeopardize their own health or safety, or other's health and safety at camp. The undersigned further agrees to pick up the camper or volunteer immediately upon being notified of such termination. The undersigned agrees not to send the applicant (to attend or volunteer), one of the BIAC Outdoor Adventure programs if he/she has been exposed to a contagious disease within three (3) weeks of the starting of camp, and to notify the BIAC if such a case should arise.

I agree

Outdoor Adventure Challenge 2010

Please select the week you would like to volunteer.

Breckenridge, Colorado (18 yrs. or older to attend)

April Fools - April 7-10
Volunteers + RN

Empire, Colorado (21 yrs. or older to attend)

Camp Summit - May 30-June 4

Breckenridge, Colorado (18 yrs. or older to attend)

Challenge-by-Choice - June 6-11
Volunteers + RN 5-11

Denver Day - June 19
Possible Volunteer Opportunity

Challenge-by-Choice - July 11-16
Volunteers + RN 10-16

Challenge-by-Choice - August 1-6
Volunteers + RN July31-Aug 6

Extreme Adventure Camp - August 22-27
Volunteers + RN Aug 21-27

Denver Day - August 29
Possible Volunteer Opportunity

Canyon Canoe Trip - September 1-5
No Volunteers

Creative Minds - September 10-13
Volunteers + RN 10-13