Form

Youth and Family Program Staff and Volunteer Application

Providence, Rhode Island at the Rhode Island Convention Center October 9 - 12, 2013
STAFF TRAINING - September 9, 2013

Applications will be reviewed on an annual basis. Filling out this form does not guarantee your participation. A representative from the Phoenix Society will contact you after reviewing your application.
Full Name*
First Name Middle Name Last Name
E-mail*

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home
- Area Code Phone Number
Cell*
- Area Code Phone Number
Business
- Area Code Phone Number
Best way to reach you*

Home Cell Business E-mail
Birth Date*
Month Day Year
Ethnicity (used for background checks)*
Certification(s)
Languages*
Languages ...*

Speak Write Read
Are you a returning volunteer? Please explain
Special skills and/or certifications: (i.e. CPR, first aid, lifeguard, crafts, musical instruments, leadership skills, foreign languages, etc.)*
Please describe your work/volunteer history with working with children. Please include specific age group*
What is your comfort level in working with/mentoring children with severe and visible burn injuries and related disabilities? Your complete honesty here is sincerely appreciated.*
How did you become interested in being involved in the UBelong program at World Burn Congress: or, what makes you choose to return?*
What do you think are your greatest strengths for working with kids in group settings? Areas that are challenging or you would like to improve?*
What age group do you prefer?*

7-10 years of age 11-13 years of age 14 -17 years of age 18-25 years of age
What survivor group do you prefer?*

Burn injured Siblings of burn injured Kids of burn injured parents Parents
Are you able to volunteer the entire time Wednesday through Saturday afternoon?*

Yes No
Please explain if you have other commitments:
Is your institution able to fund your trip expenses? (hotel, travel). If not, please indicate what assistance is needed
Any additional information or ideas you would like to share?
Will you have a family member (child or adult) attending any World Burn Congress Programs? Please explain
Please choose your preference for t-shirt size*

Small Medium Large XL XXL
Health Information/History
Do you currently have any medical problems?*

Yes No
Do you have any allergies?*

Yes No
Do you currently have or are you being treated for any infectious disease (such as HIV, Hepatitis B, MRSA)?*

Yes No
Are you currently taking any medications?*

Yes No
Do you have any medical conditions that would prevent you from participating in recreational activities? (i.e. asthma, heart problems, hypertension)

Yes No
In case of an Emergency, please notify ..*
First Name Last Name
Phone*
- Area Code Phone Number
Relationship*
Alternate Emergency Contact*
First Name Last Name
Phone*
- Area Code Phone Number
Relationship*
Please list two references ...
First reference ...*
First Name Last Name
Phone*
- Area Code Phone Number
Relationship*
Second reference ...*
First Name Last Name
Phone*
- Area Code Phone Number
Relationship*
Have you had a background check in the past year? (If yes, please download the 'Employer Background/Criminal History Check' once you have submitted this form!)

Yes No
I hereby certify that the information provided in this application is true, correct and as complete as possible. (PRINT NAME - This acts as your digital signature!)*
First Name Last Name
Date*
/ Month / Day Year

Phoenix Society for Burn Survivors World Burn Congress Volunteer Agreement

Please read and sign the below information that is used for Phoenix Society records and event insurance purposes
Volunteer Liability Release

I, the undersigned volunteer, understand that I am not an employee, agent, subcontractor, or independent contractor of the Phoenix Society. I understand that the Phoenix Society will not provide me with compensation, insurance, worker’s compensation, or any other right or benefits, whether of an employee or otherwise. I will not exert any right to ownership of any products discovered or developed while providing volunteer services. In consideration of my voluntary involvement and participation with the Phoenix Society and any of their activities and events, I hereby acknowledge and agree for myself, my children, my heirs, assigns, executors, and administrators to assume all risks associated with these volunteer activities. Further, I knowingly release, waive, discharge and hold harmless the Phoenix Society, Inc., their officers, employees, agents, successors, volunteers, assigns, Shriners Hospitals for Children, Rhode Island Hospital and University Surgical Associates from all liability, claims, demands, actions, and law suits for all injuries and damages of any type or kind sustained as a result of my involvement in such activities, whether or not resulting from negligence or otherwise. I hereby attest that my attendance and involvement in such activities is voluntary, that I am participating at my own risk, and that I have read the foregoing terms and conditions of this release. I acknowledge that my responsibilities under this Volunteer Liability Release paragraph shall survive the termination of this Agreement.
...

I hereby confirm, represent, and warrant that I have never been convicted of or charged with a violent crime, child abuse or neglect, child pornography, child abduction, kidnapping, rape or any sexual offense, nor have I ever been ordered by a court to receive psychiatric or psychological treatment in connection therewith. I understand that in the event I am assigned to serve as a volunteer in the WBC Youth and Family program during scheduled program times, minor children under the age of 18 will be present. I hereby understand and agree to follow the guidelines of having no less than 2 adults present at all times during these sessions attended by minor children.
Confidentiality Agreement

I acknowledge that in the course of my volunteer activities I may have access to documents, data, or other information whether medical, financial, personal member information or otherwise, that is confidential and privileged from disclosure. I agree to hold in confidence and not disclose such confidential information to any person or entity. Upon conclusion of my volunteer assignment, I agree to continue to treat such information as private and privileged. I understand that failure to do so constitutes a breach of confidentiality.
Background Check

I, the undersigned volunteer, authorize the Phoenix Society to receive information from the Secretary of State, State or Federal Court and any law enforcement agency, to the extent permitted by state and federal law, pertaining to any charges and/or convictions I may have had for violation of state and/or federal laws, including but not limited to traffic violations and convictions for crimes committed upon children.
...

I understand that such access is for the purpose of considering my application as a volunteer and that I expressly do not authorize the Phoenix Society to disseminate this information in any way to any other individual, group, organization or corporation.
I attest that I have read and voluntarily sign this agreement this*
/ Day / Month Year
Digital Signature*
First Name Last Name
The Phoenix Society for Burn Survivors offers equal opportunity to all, based upon individual merit and without regard to race, color, religion, national origin, sex, age, sexual orientation, height, weight, marital status or disability which, if needing accommodation, may be reasonably accommodated as required by law.
Thanks for volunteering! Your personal information will be kept confidential and will not be distributed. PLEASE COMPLETE THE ENTIRE FORM so the Phoenix Society for Burn Survivors can review your application. They will contact you to confirm your involvement in the program. Staff applications will be reviewed on an annual basis.

Phoenix Society would like to thank The Children’s Hospital Burn Camps Program for sharing portions of their application template for use in the development of this form.
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Youth and Family Program Staff and Volunteer Application

STAFF TRAINING - September 9, 2013

Health Information/History

Please list two references ...

Phoenix Society for Burn Survivors World Burn Congress Volunteer Agreement

Volunteer Liability Release

...

Confidentiality Agreement

Background Check

...