Volunteers

Being a Kamp Counselor at Kamp Kaleidoscope is the coolest way to spend a few weeks of your summer. If you are willing to work hard, learn a lot, and have tons of fun, we need you! Many of our Kounselors come back year after year to volunteer and to catch up with their past campers and counselor friends.

If you are interested in being a Kamp Kaleidoscope Kounselor next summer, please fill in the information on the form, and then click on the "Submit Information" button and someone will contact you.

I want to help with:

Summer Program

Weekend Adventures

Autism Awareness/Fundraising Events

Identifying Information:

First Name:

Middle Name:

Last Name:

Email Address:

Gender:

Female

Male

Age:

Race:

Date of Birth:

Home Telephone:

Address:

City:

State:

Zip:

Education Level:(High School, College, etc.)

School Attended:

Occupation:

For your employer:

Name

Address

City

State

Zip

Phone Number:

For your Parent or Guardian:

Name:

Address:

City:

State:

Zip:

Day Phone:

Night Phone:

For your Emergency Contact:

Name:

Address:

City:

State:

Zip:

Day Phone:

Night Phone:

Personal Information:

Do you have any chronic health conditions:

Yes

If so, describe your condition and the medications you take:

Do you smoke?

Yes

(Counselors will not be allowed to smoke in cabins or around campers)

T-Shirt Size:

Health Care Information:

Name of Primary Insurance:

Policy #:

Group #:

Name of Insured

Name of Family Doctor:

Doctor Phone:

Hospital of Choice:

* All counselors must have insurance coverage. Please send copies of insurance coverage card.

Experience:

List any experience with exceptional children:

List camp experience:

Please list any other special skills or experiences:

Certifications / Talents:

Please list any certifications you hold (Life Guard, CPR, etc.)

Do you play a musical instrament?

Yes

If so, which ones and can you bring it (them) to camp?

References

List two persons (not relatives) who have knowledge of your qualifications:

Name

Phone Number:

Address

City

State

Zip:

Position

Name

Phone Number:

Address

City

State

Zip:

Position

How did you learn of Kamp Kaleidoscope?

SR. COUNSELORS:

I understand I will be expected to attend Kamp Kaleidoscope, without leaving, for the session(s) for which I am chosen. I further understand that by submitting this form over the Internet, I am giving Kamp Kaleidoscope staff permission to conduct a background check prior to my participation.

JR. COUNSELORS:

I you are under 21 years of age, this form must be submitted by your parent or guardian.

I hereby give consent for the person named in this form to be treated by the Kamp Kaleidoscope medical staff if the occasion should arrise. I also give consent for him/her to be admittted to the hospital if an emergency should occur, allthough I understand that I will be notified as soon as possible.

TEAAM: Together Enhancing Autism Awareness in Mississippi

Volunteers

Identifying Information:

For your employer:

For your Parent or Guardian:

For your Emergency Contact:

Personal Information:

Health Care Information:

Experience:

Certifications / Talents:

References