Camp RAD Counselor Application Form

Name:______________________________________ Circle T-shirt size S M L XL XXL

Credentials: Car License Plate #: _________________
(required for Field House lot)

School or Place of Employment: ______________________________________

Phone: (Work): ___________________ (Home): ___________________

(Pager): ___________________ (Cell): ___________________

Email Address:_______________________________________________

Home Address: ____________________________ City:_______________ Zip:________

My personal goals for working at camp are:

I understand that camp is a patient care activity and that my commitment to participate in all camp events is equivalent to any other patient care staffing commitment such as inpatient or outpatient tours of duty. Failure to arrive on duty at the assigned times is equivalent to patient abandonment.

I agree/commit to all camp events which include the following:

Counselor Staff Orientation Workshops Dates:   Tuesday, May 13, 2008, 8:30 a.m. - 4 p.m. UTMB Hospital Rm: Jenny Sealy 6th Floor Auditorium
Tuesday, May 27, 2008, 9 a.m. - 4:30 p.m. Rm: TBA

Parent/Camper Orientation:   Saturday, May 17 or May 24, 12:00 p.m. - 3 p.m. SASH Lobby

Camp RAD:   Monday, June 2 - Friday, June 6, 7:30 a.m. - 5 p.m.
at the UTMB Alumni Field House

In the event that an unforeseen circumstance arises affecting my participation at camp events, I understand that it is my responsibility to notify the Camp Director immediately.

Signature:_________________________________________________

Date: ________________________

NOTE! If you work for hire, you are required to have the following section completed by your supervisor. This is a requirement for participation in camp.

As the immediate supervisor for, ________________________________________

(Name of Employee)

I agree that he/she has permission to be released from his/her usual duties to participate in the Camp RAD workshops, to staff camp and to participate in the final evaluation as specified by the dates listed above.

Name of Supervisor:

Title:

Date:

PLEASE RETURN THIS APPLICATION TO:

Anne Meng, M.N., C.P.N.P., Camp Director
The University of Texas Medical Branch Dept. of Women's, Infant's and Children's Nursing
301 University Blvd. Galveston, TX 77555-0473
(409) 772-0687