GUIDED DISCOVERIES, INC.
CERTIFICATION OF EMPLOYEE
The undersigned Employee has accepted employment with Guided Discoveries, Inc., a California
non-profit corporation, (“Employer”), under a written Employment Agreement to which this
Certification is attached and incorporated by reference. Employee understands that this
Certification is a material part of the consideration for his or her Employment upon which
Employer has relied and based thereon makes the following representations and warranties:
I have read and will abide by all provisions of the Employee Handbook given to me, including
those regarding appearance and conduct.
I understand that employment as stated in the Employment Agreement is an employment at will.
Either employee or employer may terminate with or without cause at any time.
I will not accept gratuities or tips for campers, parents, teachers or others attending any of
Employer’s programs or associated with those attending one. I will report any offered tips or
gratuities to my supervisor.
I certify that I possess each of the minimum qualifications required for the position as outline on
the attached job description.
I also understand the “Employer” maintains a drug-free work environment and that possession
or use of illegal drugs or narcotics during the term of my employment is forbidden and will
result in immediate termination of my employment and may be reported to local authorities.
If requested by Employer, I agree to be fingerprinted and I will voluntarily submit to a drug test.
I understand that reporting to work while under the influence of alcohol or consuming any
alcoholic beverage during working hours will result in immediate termination of my
employment.
I agree to vacate any housing provided to me by the
“Employer” within 24 hours after the termination of my employment. (See the housing
agreement for further clarification.)
Although the company does its best to keep all staff informed of changes, I understand and agree
that my Employer has the right to change, modify, amend, or delete any policies, practices,
benefits as deemed appropriate without notice in its sole and absolute discretion.
Guided Discoveries, Inc.
By
Employee
Director
Date
Revised 05/02
Code of Safe Practices
General Area or Specific Job Safety Class: General
Safe Workplace Conditions:
1. Areas should be clean and clear of debris and obstructions.
2. Any equipment or materials used must be in good working order.
3. All lights must be working to provide proper illumination of the area.
4. Supervisor must be aware of your work location at all times.
Safe Work Practices:
1. Take necessary precautions when in or near the water.
2. Employees must be trained in proper use of equipment.
3. Any water activities must be with a designated partner.
4. Dress appropriately for work. Avoid loose clothing around tools and machinery.
5. Keep hands clean and free of oils or contaminants.
6. Use proper lifting techniques when necessary.
7. Report all injuries or illness to your supervisor.
8. In the event of a fire, call for supervisor and sound alarm.
9. Upon sounding fire alarm, direct your group to designated fire drill location, and wait
for further directions.
10. No smoking or use of illegal drugs and intoxicating substances.
11. Stay more than 30 yards away from wild animals. Do not feed or throw them things.
12. Use flashlights for evening work-related activities and programs.
13. Do not ride bicycles during work hours unless approved.
14. Staff must be trained in use of equipment and vehicles before using them.
15. Always yield to pedestrians in camp when driving or riding bicycles.
General Facility:
1. Road gates should be closed at appropriate times to prevent through traffic.
2. Railings along the deck behind the dining hall and around the second floor of the
classroom building should not be sat on or climbed upon.
3. Saunders Meadow Road runs all around the facility and has frequent traffic, so staff is
advised to take caution when walking off of the facility grounds.
4. Fire rings may only be used when permission is granted and fires must be doused
before the last person leaves the fire area.
5. During the winter months, staff must be careful of slipping hazards from ice and snow.
Pool Area:
1. Unauthorized use of the pool is prohibited.
2. Staff must follow pool guidelines to use the pool when not in program.
3. Staff may not use pool alone, must have at least one person to act as lifeguard.
4. Pool rules must be followed at all times.
Ropes Course:
1. Unauthorized use of the Ropes Course is prohibited.
2. The ropes course instructor or his assistant must supervise when in use.
3. Staff must be attentive and aware when near the ropes course in case of slips and falls.
Gym Area:
1. Unauthorized use of the gym is prohibited.
2. One may use the climbing wall when permission is granted and someone with the
proper training is teaching belaying.
3. Lights must be turned on when using the gym.
Shop Areas:
1. Shops and tools must be properly secured to prevent unauthorized use.
2. Only authorized personnel will be allowed to utilize shop areas.
3. The Maintenance Director based on an individual’s proven need, experience and
qualifications determines authorization.
4. Permission to use any of the equipment located in the shops or storage areas must be
obtained from Maintenance Director or his representative.
5. Maintenance Director must have knowledge that the individual seeking to use the shop
has obtained proper training on the equipment requested before using. If employee has
not received proper training, at his earliest convenience, Maintenance Director will see
that employee is properly trained.
6. After permission to use tools / equipment is granted, employee assumes responsibility
for all items used.
7. All individuals using the shop areas, using the shop areas, tools, and / or equipment
must follow all safe operating procedures and use proper safety equipment (i.e. safety
glasses, ear plugs, gloves, etc.). They must also be aware of persons working or present
in the same vicinity and warn of any possible danger.
8. All individuals using equipment and tools must inspect them prior to initial use to
ensure good repair.
9. If equipment is to be used for extensive periods of times, such as a major project,
periodic inspections must be made on the equipment.
10. All equipment must be properly stored after its use. In the case of stationary power
equipment such as table saws and drill presses, the power supply must be disconnected
and the equipment cleaned and properly serviced.
11. When the work has been completed in the shop or outside work area, the area shall be
cleaned, organized and properly secured.
Personal Protective Equipment
1. Proper clothing or attire.
2. Proper protective safety equipment when necessary.
3. Sunglasses, hats and sunscreen when working in direct sun.
Code of Safe Practices
General Area or specific Job Safety Class: Program
1.
2.
3.
4.
5.
6.
7.
8.
Secure supervisor approval before beginning all work
Dress properly for work. Avoid clothing around tolls and machinery.
Wear safety glasses when performing any operation that may endanger your eyes.
Be sure that you have good light to see what you are doing with out straining your eyes.
Keep hands clean and free of oils or contaminants.
Consider others when working and be careful not to endanger yourself or others.
Use proper tools for the job. Never use tools that are dull or not in good condition.
Keep your work area clean and floor free of obstacles. Store all tools and materials in their proper
location at the completion of your job.
9. Protect your back muscles when lifting. Secure help with heavy or large items.
10. Report all injuries or illness to the supervisor or safety coordinator.
11. Report all unsafe conditions to the supervisor or sound alarm.
12. In the event of a fire, call for supervisor or sound alarm.
13. Upon hearing fire alarm, report to designated area with group and await further instructions.
14. Only training and designated workers may attempt to respond to a fire or other emergencies.
15. No horseplay or use of intoxication substances is allowed in the program facilities.
16. No smoking except in designated areas.
17. Shoes must be worn at all times during working hours.
18. Never approach closer than 30 yards of wilds animals. Do not feed or throw items at wild animals.
19. Use flashlights to guide yourself through the facility during evening program or work-related activates.
20. Bicycles are not approved or recommended to be used during work hours.
21. Unauthorized use of facility equipment, vehicles or tools is prohibited.
Workplace Safety Conditions:
1. All equipment should be in good working order before using.
2. Areas should be clean and free of any obstacles or potentially dangerous items.
3. All lights should be working properly to provide proper illumination of work area.
4. Supervisor must be aware of your work locations or destinations before beginning work.
Personal Protective Equipment:
1. Proper and adequate clothing or attire should be worn for all jobs.
2. Sunglasses, hats and sunscreen are recommended while working outdoors.
General Area or specific Job Safety Class: Lights and Lasers
1. The floor must be dry, clean and clear of debris and obstructions.
2. The remote control Light for the room must be accessible and in working order.
3. The lab equipment must be in good working order and in the correct positions.
Safe Work Practices:
1. Employees must use a red flashlight or remote control room light while operating equipment in the
light room.
2. Employees must be trained in proper use of lasers, Tesla coil, and strobe disk.
Personal Protective Equipment:
1. Remote control light switch.
2. Red flashlight.
General Area or specific Job Safety Class: Lab tech office and Repair Shop
Safe Workplace Conditions:
1. Room should be kept clean and orderly with tools and equipment properly stored away.
Safe Work Practices:
1. Employees must read and follow the safety instructions for the small equipment repair tools before
using.
2. Tools should only be used for their intended job only. Use the right tool for the right job.
3. First aid supplies must be kept in the shop.
General Area or specific Job Safety Class: Microgravity Lab and Pool
Safe Work Conditions:
1. The pool deck and tent must be free of debris and obstructions.
2. There must be circuit breakers on all drop cords
3. Warning signs shall be posted.
4. The protective grate around the gas heater shall remain in place.
5. The storage area shall be kept clean and in good order.
6. Carpet or non-skid surface shall be placed in the dressing room floor.
7. All safety equipment shall be in good condition.
8. The number of bees in the area shall be controlled through the use of Bee traps or other means.
Safe work Practices:
1. No running in the pool.
2. Employees should not be in the pool without another adult present. Unauthorized use of the pool is
prohibited.
3. No employee should misuse safety or cleaning equipment.
4. The class will be cancelled if there is any lightning in the area.
5. Employees shall obey all warning information signs that are posted.
6. The heater shall not be left unattended when it is running.
7. Employees should use chairs to sit on, not the folding tables.
8. Extension cords should be kept up and off of the deck surface.
9. No bottles are to be brought into the tent or pool area.
10. Employees should check the radio to make sure that it is in service before each class.
Personal Protective Equipment
1. Life rings, rescue poles, life jackets, goggles, back board, first aid supplies and radio should be present
and in working order at all times.
General Area or Specific Job Safety Class: Telescopes Lab
Safe Work Conditions:
1. The lights in area should be turned on for setting up the equipment and for taking it down.
2. The viewing area must be dry with no ice on the surface.
3. The area should be free of debris and obstructions.
Safe Work Practices:
1. Employees use a flashlight when conducting class in order to facilitate moving around.
2. Employees should never carry heavy equipment by themselves.
3. Electrical equipment should not be set up on wet surfaces.
4. Employees should dress appropriately for the weather conditions.
Personal proactive Equipment:
1. Red flashlights will be available for employees to use during the telescope class.
General Area or Specific Job Safety Class: Planetarium
Safe Work Conditions:
1. Laser pointer and projector must have circuit breakers on them.
2. The laser pointer, projector and fan must be in good working order.
3. The planetarium must be clear of obstruction and debris.
Safe Work Practices:
1. Employees enter and exit the dome using a flashlight to facilitate movement.
2. If any equipment is damaged it must be reported.
3. Each employee must be trained on the use of the laser pointer and planetarium projector prior to use.
General or Specific Job Safety Class: Hiking and Night Hike
Safe Workplace Conditions:
1. Hikes shall remain on clearly marked trails ands away from known hazards
Safe Work Practices:
1. Employee shall wear appropriate clothing and footwear for conditions on the trail.
2. Employees shall keep in good physical condition.
3. Employees shall learn where and types of hazards are present or possibly present in the hiking area,
such as bees, snakes, slides, ect.
4. First aid supplies and bottles of water must be taken on the hike.
5. All employees on night hike should carry a working flashlight.
Personal Protective Equipment:
1. Flashlights are needed on all night hikes.
2. First aid supplies are necessary for every hike.
General area or Specific Job Safety Class: Atmosphere and Gases
Safe Workplace Conditions:
1. Floors shall be kept dry and equipment in its correct area.
2. Circuit breakers are necessary for all electrical equipment.
3. The room should be well ventilated at all times.
Safe Work Practices:
1. All employees should be trained in the safe use and hazards of the vacuum pump.
2. Dry ice is only to be handled using insulted gloves.
3. Goggles are to be worn during demonstrations using chemicals or hot liquids.
4. Gas fittings. Hoses, ad valves must be inspected on a regular basis.
Personal Protective Equipment:
1. Employees shall wear insulted gloves.
2. Goggles or a face shield shall be worn.
3. Fire extinguishers and fire blankets shall be readily available.
4. The water rinse system shall be available for use.
General Area or Specific Job Safety Class: Rocket Launch Area
Safe Workplace Conditions:
1. Pressure gauges and launch pads must be in good working order.
2. The launch area must be free of debris, obstructions and slip, trip, and fall hazards.
Safe Work Practices:
1. The rockets must be checked for scratches or dents that weaken the container, and such rockets must
be discarded.
2. All equipment must be stored away in the storage area.
3. Employees must remain a safe distance away from the launch pad when the rocket is being launched.
Personal Protective Equipment:
1. Hard hats, face shields or goggles, and the employee must wear ear protection during fueling and firing
the rocket.
General Area or Specific Job Safety Class: Ropes Course Instructors and Assistants
Safe Working Conditions:
1. Ropes, carabineers, harnesses, helmets and all other equipment needed will be provided to all staff in
good condition.
2. The ropes coursed will be examined (and repaired if necessary) for unsafe conditions such as debris
build up around the course or damaged equipment prior to use.
Safe Work Practices:
1. All employees will use proper belaying techniques on the ropes course at all times.
2. All employees will wear proper clothing and footwear on the course.
3. Employees will go through a complete safety lecture prior to going on any element of the ropes course.
4. Employees will abide all rules established by the ropes course APD on the course.
Personal Protective Equipment:
1. Employees shall wear safety equipment at all times while on the ropes course including helmets,
harnesses, ect.
General Area of Specific Job Safety Class: Star Gallery and Stars Class
Safe Workplace Conditions:
1. The area must be clean and orderly with no obstructions or trip, slip and fall hazards.
Safe Work Practices:
1. Employees should enter the building through the side doors where there is a light switch.
2. Use a red flashlight when moving from place to place when lights in the room are turned off.
Personal Protective Equipment:
1. A flashlight should be available for use in the room at all times.
EMPLOYEE ACKNOWLEDGEMENT OF REVIEW AND
RECEIPT OF THE
GENERAL & PROGRAM CODE OF SAFE PRACTICES
Dear Staf Member,
Attached is a copy of the General and Program Code of Safe Practices. These guidelines are provided
and designed for your safety.
It is your responsibility of your supervisor to provide and review this code with you. It is your
responsibility to read and comply with this code.
After reviewing the attached documents, please sign and date below. These must be returned to your
supervisor.
GENERAL CODE OF SAFE PRACTICES
I have read and understand the General Code of Safe Practices
Date:
Employee Signature:
PROGRAM CODE OF SAFE PRACTICES
I have read and understand the Programl Code of Safe Practices
Date:
04/2011 MFP
Employee Signature:
Employee Handbook Acknowledgment Form
This is to acknowledge that I have received a copy of the Employee Handbook and understand
that it contains important information on the Company’s general personnel policies and on my
privileges and obligations as an employee. I acknowledge that I am expected to read, understand
and adhere to company policies and will familiarize myself with the material in the handbook. I
understand I am governed by the contents of the handbook and that the company may change,
rescind or add to any policies, benefits or practices described in the handbook, other than the
employment at will policy, from time to time in it’s sole and absolute discretion, with or without
prior notice. The Company will advise employees of material changes within a reasonable time.
Furthermore, I understand that employment with the Company is not for a specified term and is
at the mutual consent of the employee and the Company. Accordingly, either the employee or
the Company can terminate the employment relationship at will, with or without cause, at any
time. This represents an integrated agreement with respect to the at will nature of the
employment relationship.
Print Name:______________________________________________________________
Signature:_______________________________________________________________
Date:________________
Facility: Astrocamp
Job Title: Instructor
CONFIDENTIAL
GUIDED DISCOVERIES EMPLOYEE EMERGENCY
INFORMATION AND HEALTH HISTORY
Name:
Birthdate:
Facility: Astrocamp
Position: Instructor
Soc Sec #:
Permanent Address:
Street
City
State
Zip
In case of an Emergency, please contact:
Name
Address
Phone #
Relationship
Please check the following that apply to your recent past (2 years) or present medical condition. The information provided is for
medical emergency purpose only - it benefits you in case of an emergency. It does not affect your employment status.















Asthma, emphysema or tuberculosis
Frequent colds or Bronchitis
Diabetes
Respiratory problems or disease (please state below)
Seizures, dizziness, fainting or blackouts (please state below)
Heart condition (please state below)
Recent injury, illness or operation (please state below)
Frequent headaches or migraines
Back or neck disorders (please state below)
Joint disorders, such as knees, fingers, wrists, ect. (please state below)
Allergies (please state below)
Eating disorders
Currently taking prescrition drugs long term (please state below)
Bloodborne disease (please state below)
Any communicable disease (please state below)
If you marked any of the above, please explain the condition including the date and list any other relevant conditions not listed.
To my knowledge, the information listed above is correct. In case of an emergency, I hereby give permission to
Guided Discoveries and its facilities to arrange transportation to the nearest medical facility. I also give
permission to the attending physician to secure and administer the necessary treatment, which may include
hospitalization.
Employee Signature
Date
Guided Discoveries, Inc.
APPLICATION FOR EMPLOYMENT
GUIDED DISCOVERIES IS AN EQUAL OPPORTUNITY EMPLOYER
Astrocamp • P. O. Box 3399 • Idyllwild, CA 92549
Catalina Island Marine Institute (CIMI) at Toyon Bay • P. O. Box 796 • Avalon, CA 90704
Catalina Island Marine Institute (CIMI) at Cherry Cove • P. O. Box 5015 • Two Harbors, CA 90704
Catalina Island Marine Institute at Fox Landing • P. O. Box 1920 • Avalon, CA 90704
CIMI Tall Ship Expeditions • P. O. Box 32085 • Long Beach, CA 90832-2085
Guided Discoveries, Inc. • P. O. Box 1360 • Claremont, CA 91711 • 909.625.6194 • 909.625.7305 (Fax)
www.GuidedDiscoveries.org • webmaster@GuidedDiscoveries.org
Position(s) Applied For
Date of Application
Have You Ever Applied Here Before?
When?
PERSONAL INFORMATION
Name
For Which Facility or Program?
Social Security Number: _____-___-______
(Last/First/Middle)
Present Address (Street/City/State/ZIP)
Permanent Address (Street/City/State/ZIP)
Phone Number(s)
Driver License Number
EDUCATION (Most Recent First)
Name of School and Location
State
Degree and
Date Received
Expiration Date
Major Course
of Study
Awards or
Honors Received
List any additional coursework or experience that pertains to the position(s) for which you are applying:
Have you ever been convicted of a child abuse crime? Yes ‘ No ‘
If yes, pleaseexplain:___________________________________________________________________________________________
Have you ever been convicted of a felony? Yes ‘ No ‘ Note: A conviction will not necessarily disqualify an applicant from employment consideration.
If yes, please explain:__________________________________________________________________________________________
Can you, after employment, submit verification of your identity and legal right to work in the United States? Yes ‘
Are you able to physically perform the duties of the job for which you are applying?
Yes ‘
No ‘
No ‘
Can you, with or without reasonable accommodation, perform the functions of the job? Yes ‘ No ‘
Please describe how you will perform these functions:________________________________________________________________
Can you meet the attendance requirements of this job? Yes ‘ No ‘
How many days of leave did you take during the last year of your most recent job?_________________________________________
Work Experience - Beginning With The Most Recent
Employer
Address
Phone
Job Title
Dates Employed (From / To)
Reason for Leaving
Supervisor
Work Performed
Employer
Address
Phone
Job Title
Dates Employed (From / To)
Reason for Leaving
Supervisor
Work Performed
Employer
Address
Phone
Job Title
Dates Employed (From / To)
Reason for Leaving
Supervisor
Work Performed
Employer
Address
Phone
Job Title
Dates Employed (From / To)
Reason for Leaving
Supervisor
Work Performed
Salary Desired:_____________________________________________________________________________________
Are you currently employed?
Yes ‘ No ‘
May we contact your current em ployer?
Yes ‘ No ‘
On what date would you be able to start work?____________________________________________________________
Please list any job related organizations, clubs or professional societies to which you belong. Incl ude any job related
certifications and their expiration dates. You may exclude those which indicate race, rel igion, national origin, color, age
or other protected status.
_________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
References
Please list three people who have supervised you in previous employment and w hom w e may con tact.
Name
Address
Phone
Business
Years Known
Name
Address
Phone
Business
Years Known
Name
Address
Phone
Business
Years Known
Applicant Statement
The facts set forth in this application are true and complete. I understand that if employed, false statements on this
application are cause for dismissal. I hereby authorize Guided Discoveries to make an investigation of my
employment and personal history through any investigative or credit agencies of its choice to verify the information I
have provided on this application. I understand I that I will receive notice of any such investigation.
I understand I will be required to consent to a pre-empl oyment drug test as a condition to being considered f or
employment. If I am employed, I consent to random drug and alcohol testing as a condit ion of my continued
employment. I understand that my failure to consent to these test or a test result which shows the presence of
drugs will result in removal from consdieration or disciplinary action, up to and including termination, even for a first
offense.
I understand that under California law, and as a condition of employment, I may be required to submit to
fingerprinting and a criminal records investigation by the California Department of Justice. I understand that my
failure to sonsent to such fingerpri nting will result in removal from consideration or termination.
I further understand that if employed by Guided Discov eries, my employment is at will and the em ployer/employee
relationship may be terminated at any tim e by either party with or without cause. I agree to abide by all rules and
policies of Guided Discoveries as set forth in the Employee Handbook and during staff training including those
pertaining to safety, conduct and appearance at the facilities.
_____________________________________________________________
Signature of Applicant
_____________________
Date
GUIDED DISCOVERIES, INC.
ASTROCAMP
EMPLOYEE RELEASE & WAIVER OF LIABILITY
This Release, Waiver and Covenant Not To Sue is made by and between the undersigned
(“Employee”)
(name)
and Guided Discoveries, Inc., a California corporation (“GDI”) in consideration of the use and
operation of the equipment, facilities and property of GDI.
Upon Employee’s request in consideration of his/her Guest/s during off duty hours, and after
appropriate training, sign off and approval from Employee’s supervisor and the Director in
charge of the various items listed below, Employee and Guest/s will use, operate and have
possession of various types of equipment, gear, facilities and machines which are the property of
GDI. This release is used as a Waiver of Liability while using GD property and does not give
Employee and Guest/s the right to use any of the below-mentioned items if prior approval is not
granted, if items requested are not available for use, or if items are prohibited for use be an
Employee and Guest/s. This includes, but is not limited to:
Dive and Scuba Equipment
Swimming Pool and Equipment
Gymnasium and Equipment
Wetsuits
Ropes Course, climbing walls/devices
Sports Fields and sporting games such as soccer, volley ball, etc.
Hiking equipment
Hiking trails, bicycle trails, roads
Weight training equipment
By signing this agreement, Employee and Guest/s of Employee certifies:
1. That he/she has read and signed the Employee/Guest Policy, been thoroughly trained in the
use and operation of the Equipment and is aware of the inherent dangers and risks involved
in the use of all Equipment that Employee may request for personal use with Guest/s during
his/her off duty time.
2. That the Equipment will only be used in accordance with the Equipment operating
instructions and pursuant to the training received, in a proper, safe and reasonable manner.
3. That the Guest/s and Employee will observe all GDI’s policies, rules, regulations and
directives regarding the use and operation of the Equipment.
4. That the Employee with Guest/s will not use any Equipment that is not in good and operable
condition and will immediately report any damage, defect or fault with any Equipment to the
Employee’s supervisor or facility Administrator.
5. That the Employee and Guest/s understand that the use of certain Equipment requires
strenuous physical exertion and strength and inherent risk of harm, injury and death. With
this understanding in mind, Guest/s and Employee will not attempt to use any such
Equipment that exceeds his/her physical health, strength, ability or training at the time of
such intended use. Guest/s and Employee assume the risk of physical harm, injury and death
resulting from the use of such Equipment. Guest/s and Employee also assume the
responsibility for any damage/s to Equipment. If damage is sustained during use by
Employee/Guest/s, the incident must be reported to Employee’s supervisor and if deemed
6.
7.
8.
9.
negligent on the part of the Guest/s and employee, fair and suitable compensation from the
Guest/s and Employee may be necessary.
That Employee and Guest/s will not attempt to use or operate any Equipment, at any time or
circumstance, if under the influence of any prescription or non-prescription medicine, drug,
substance or alcoholic beverage.
Guest/s and Employee hereby waives, releases and agrees not to sue GDI, its agents,
servants, employees, officers and directors for any harm, personal injury, damage including
death resulting from Guest/s/Employee’s use of any Equipment and expressly assumes the
risk of any and all such harm arising from the use, operating and possession of any
Equipment.
This instrument is intended to be a Waiver, Release and Promise Not To Sue GDI for any
harm or injury arising from Guest/s and Employee’s use of Equipment. It is not intended to
affect GDI’s responsibility to provide Worker’s Compensation Insurance coverage for
Employee for work related injuries. However, Employee expressly agrees that use of the
Equipment for Employee’s personal purposes during off duty hours is not and shall not be
construed as Work-Related or as an activity within the scope of Employee’s Employment
with GDI.
This Agreement shall be binding upon and inure to benefit of the heirs, executors and assigns
of the parties hereto.
__________________________________
Employee’s Signature
_________________________
(date)
04/2011
____________________________________
Director Signature
_________________________
(date)
employee enrollment
application
Blue Shield plans for 51+ employees
Employee instructions
Local Access+ HMO
1. Answer all questions as completely and accurately
as possible.
• To enroll in a Local Access+ HMO® plan, you must
live or work within the Local Access+ HMO service
area. See the benefit summary and disclosures in
your pre-enrollment book.
3. Provide the Social Security number for each
member enrolling.
4. Review and complete all questions in Section 4 – Life
insurance beneficiary.
5. You must sign and date Section 5. Blue Shield of
California and Blue Shield of California LIfe & Health
Insurance Company (Blue Shield Life) cannot process
the application without signed authorization.
Important enrollment guidelines for
medical coverage
Access Baja HMO
• To enroll in an Access Baja® HMO plan, you must live
or work within the Access Baja service area.
• Refer to the Access Baja HMO Provider and Pharmacy
Directory at blueshieldca.com or call (800) 248-5451 for
customer service in Spanish or English for selection of
Personal Physician and service area information.
• Legal requirements for and generally accepted practice
standards of medical care in Mexico are different
from those of California or elsewhere in the United
States. Therefore, the care received through providers
in Mexico in the Access Baja HMO health plan will
be care that is consistent with generally accepted
medical standards of Mexico, not of California.
Access+ HMO SaveNet
• Refer to the provider directory at blueshieldca.com
for selection of your Primary Care Physician, or
contact Member Services at (800) 424-6521 for
a printed version.
Medical coverage for your dependents
Check the “Medical” box in the “Enroll in” column
for each dependent listed in Section 3. In the space
provided, list all eligible dependents you wish to enroll
(including spouse or domestic partner), their dates of
birth, and Social Security number, and check the box
to indicate relationship to the employee. If selecting an
Access+ HMO or Added Advantage POSSM Plan, you must
choose a Personal Physician. Please enter the name,
provider number, and the IPA number.
If a dependent is over 18 and under 25, you must check
the “Full-time student” box in Section 3 for each appropriate dependent this applies to. To be considered a
full-time student, dependent children ages 19 through 24
must be enrolled full-time (minimum of 12 units) in
college, trade school, or on an approved medical leave
of absence from a college or trade school. Blue Shield
of California/Blue Shield Life will deem this completed
information to be a certification of full-time student status.
Dependent coverage for full-time students over age 18
is not available to dependents of legal guardians.
If a dependent over the age of 18 is disabled due to
a physical or mental injury or illness, you must check
the “Disabled” box in Section 3. You will be required to
submit a physician’s written certification of the disability
or confirmation that your current health carrier is
providing coverage for this disabled dependent.
• To enroll in an Access+ HMO® SaveNetSM plan, you
must live or work within the SaveNet service area.
See the benefit summary and disclosures in your
pre-enrollment book.
Important enrollment guidelines for Specialty
Benefits coverage
• Refer to the provider directory at blueshieldca.com
for selection of your Primary Care Physician, or
contact Member Services at (800) 424-6521 for
a printed version.
An employee may enroll in a dental plan without
enrolling in a Blue Shield of California/Blue Shield Life
health plan.
C15390 (2/10)
Dental coverage
In order for a dependent to enroll in a Blue Shield of
California dental plan, the employee must be enrolled
in the same dental plan.
C15390-FF (2/10)
(Example:  Access+ HMO® 5-0 Inpatient
Or
 Shield Spectrum PPOSM Plan 500-90/70
An Independent member of the Blue Shield Association
2. Check the box(es) to indicate your coverage selection
and fill in plan name as appropriate.
blueshieldca.com
Vision coverage
An employee may enroll in a vision plan without enrolling
in a Blue Shield of California/Blue Shield Life health plan.
In order for a dependent to enroll in a Blue Shield of
California/Blue Shield Life vision plan, the employee must
be enrolled in the same vision plan.
The Shield Spectrum PPOSM plans, the Shield Spectrum
PPO Savings Plus plans, and the Blue Shield Life Active
ChoiceSM plans exclude pre-existing conditions.
Pre-existing conditions are covered only after you have
been continuously covered for six (6) consecutive months
including your present employer’s waiting period, if any.
The pre-existing condition does not apply to:
Life insurance coverage
• Pregnancy benefits;
An employee may enroll in a life insurance plan without
enrolling in a Blue Shield of California/Blue Shield Life
health plan.
•Newborns or adopted children who had prior
creditable coverage within thirty (30) days of their
birth, adoption, or placement for adoption, and
who enrolled in one of the Blue Shield of California
or Blue Shield Life plans within sixty three (63) days
of that prior creditable coverage (excluding any
waiting period);
If the employer offers dependent life insurance coverage,
and the employee chooses life plus dependent life
insurance coverage, and the employee and any dependents enroll in a Blue Shield of California/Blue Shield
Life health plan, then the employee and all dependents
covered by the health plan will be enrolled in the life
insurance plan.
If the employer does not offer dependent life insurance
coverage, only the employee can be enrolled in a life
insurance plan.
Refusal of Personal Coverage Form
This form (located in Section 6 on the last page of this
enrollment form) is to be used for all employees who
decline coverage for themselves or their dependents.
Enter the employee name. Check the appropriate box if
you, your spouse/domestic partner, or dependent(s) are
declining health and/or dental coverage. Check the box
that meets your reason for refusing coverage for you,
your spouse/domestic partner, or dependent(s). Indicate
the name of the other health and/or dental insurance
carrier with whom you or your dependents have
coverage. Sign and date if you have refused personal
or dependent coverage.
•Employees and dependents who were validly
covered under the present employer’s previous group
health coverage when that coverage was terminated
and who are enrolled on the original effective date,
of the Blue Shield of California or Blue Shield Life
Health plan within (63) days of the termination of
that previous coverage.
To get credit for any prior creditable coverage, obtain
a Certificate of Creditable Coverage from your prior
employer, insurer, or health plan, and submit the
certificate to Blue Shield of California/Blue Shield Life.
If assistance is required, please contact your Blue Shield
Customer Service Representative. Blue Shield of
California/Blue Shield Life protects the confidentiality
and privacy of your personal and health information.
Personal and health information includes both medical
information and individually identifiable information, such
as your name, address, telephone number, and Social
Security number. We will not disclose this information,
except as permitted by law.
The pre-existing condition exclusion
The Health Insurance Portability and Accountability
Act of 1996 (HIPAA) is a federal law that limits when
coverage may be excluded for pre-existing conditions.
Under the law, if a person’s health coverage terminates,
and he or she enrolls in new health coverage within
63 days (excluding any waiting period), the new
coverage must credit the time he or she was enrolled
in the prior coverage toward the new coverage’s
pre-existing condition exclusion. In addition, the state
law requires that the time a person was enrolled in
prior coverage be credited if he or she enrolls in new
coverage within 180 days (excluding any waiting
period) if the “prior creditable coverage” was
employer-sponsored coverage.
C15390 (2/10)
Employee enrollment application (for 51+ employees)
Page 2
Employee Application (for 51+ employees)
Blue Shield of California and Blue Shield
of California Life & Health Insurance Company (Blue Shield Life)
 New enrollment hire date _________
______ (mm/dd/yyyy)
Are you enrolling your spouse/domestic partner or dependent children in any Blue Shield
of California plan at this time?  Yes  No If yes, complete page 4 of application.
 Re-hire date ______________ (mm/dd/yyyy)
Section 1 – Employee information
Social Security number
Employer (group) name
999-99-9999
Guided Discoveries, Inc.
Last name
First name
Last Name
Internal use only.
Do not write in shaded area.
Please type or print clearly. Use black ink.
Dept code
Group number
Middle initial
Effective date (mm/dd/yyyy)
Initial
First Name
BU
Mailing address (street, city, state, ZIP)
TOC
Home address – required for all HMO and POS (street, city, state, ZIP)
Life/AD&D insurance or salary amount
Camp Address
Permanent Home Address
Home phone number
999-999-9999
NP
RSN
PKG
E-mail address name@email.com
How would you prefer we contact you?  E-mail  Standard mail  Telephone (Blue Shield of California/Blue Shield Life will use your preferred method when possible)
Are you a full-time employee, actively working at least 30 hours per week for this employer?
 Yes  No If no, please explain.
11/11/1111
Birthdate (mm/dd/yyyy) ______
________________
Gender  Male  Female
Job title/classification
Marital status  Single  Married  Domestic partner
Language preference:  English  Spanish  Chinese  Vietnamese  Other __________ (Note: Your language preference may be indicated on your ID card)
Access+ HMO or Added Advantage POS only:
Name of primary care physician
Provider number
IPA/MG number
Dental HMO only: Name of dental provider
Existing patient?  Yes  No
Dental provider number
If you, your spouse/domestic partner, or your dependent(s) are refusing coverage, please complete and sign the Refusal of Personal
Coverage Form on page 6.
Section 2 – Plan(s) Check and fill in plan name(s) as appropriate (see Important Enrollment Guidelines on page 1).
Plans for 51+ employees
Medical benefits
HMO 10-0 IP
 Access+ HMO _______________________________
 Access+ HMO SaveNet _________________________
 Local Access+ HMO ____________________________
 Added Advantage POS __________________________
 Access Baja HMO _____________________________
 Active Choice* _______________________________
 Shield Spectrum PPO ___________________________
 Shield Spectrum PPO Savings Plus1 _________________
 Core Flex Basic1 ______________________________
 Core Flex 70/50 _______________________________
 Core Flex 80/60 _______________________________
 Core Flex 90/70 _______________________________
 Core Flex 90/70 Premier _________________________
 Core Flex Basic HMO 45_________________________
 Core Flex HMO 40 _____________________________
 Core Flex HMO 30 _____________________________
 Core Flex HMO 20 _____________________________
 Other ______________________________________
Plans for 300+ employees
 100/50 PPO Plan A or B _________________________
Tax savings options (for Blue Shield use
only) Please indicate if you plan on enrolling
in any of the following options (check all
that apply):
C15390 (2/10)




Specialty Benefits
$25,000
 Life insurance* ___________________________________________
 Dental PPO ______________________________________________
 Dental HMO _____________________________________________
 Vision with a Blue Shield medical plan __________________________
 Vision without a Blue Shield medical plan* _______________________
 Other __________________________________________________
Core Flex dental plans
 Core Flex Basic Dental PPO 75/1000/No Ortho/MAC
 Core Flex Dental PPO 50/1000/No Ortho/MAC
 Core Flex Dental PPO 50/1000/Ortho/U90
 Core Flex Dental PPO Premier Plus 50/1500/Ortho/U90
Core Flex vision plans
 Core Flex Vision Standard 0/25/75
 Core Flex Vision Plus 0/10/100
 Core Flex Vision Deluxe 0/0/130
* Underwritten by Blue Shield of California Life & Health Insurance
Company (Blue Shield Life).
1 Shield Spectrum PPO Savings Plus and Core Flex Basic are HSA-eligible,
high-deductible health plans. Note: Blue Shield does not offer tax
advice, nor do we offer HSAs, HRAs, or FSAs.
Health Savings Account through (name of administrator): ___________________________________________
Health Reimbursement Arrangement through (name of administrator):__________________________________
Flexible Spending Account through (name of administrator): ___________________________________________
Premium Only Plan through (name of administrator): ______________________________________
Employee enrollment application (for 51+ employees)
Page 3
Section 3 – Dependent information
Access+ HMO and Added Advantage POS applicants must select a primary care physician in the Blue Shield Access+ HMO physician and hospital directory.
Access+ HMO SaveNet applicants must select a primary care physician in the Blue Shield Access+ HMO SaveNet physician and hospital directory. Local
Access+ HMO applicants must select a primary care physician in the Blue Shield Local Access+ HMO physician and hospital directory. Dental HMO
applicants must select a dental provider listed in the dental HMO provider directory. You may choose a different Access+ HMO primary care physician
for each family member; your dependents must live (or work) in the physician’s IPA service area. Be sure to include each primary care physician’s name,
provider number and their IPA number as well as each dental provider name and provider number (see coverage for your dependents on page 1 and 2).
Dependent’s address, if different from employee – please indicate which dependent(s) this applies to:
Dependent information
Enroll in
 Spouse  Domestic partner
 Male
 Female
First
MI
Last
 Medical
 Dental
 Vision
Social Security number
Access+ HMO and Added Advantage
POS only – name of Personal Physician
Dental HMO only – dental provider
Doctor’s name
Dental provider name
First
First
Last
Last
Provider number
Dental provider number
IPA/MG number
Date of birth (mm/dd/yyyy)
Existing patient?  Yes  No
Existing patient?  Yes  No
Doctor’s name
Dental provider name
First
First
Last
Last
Social Security number
Provider number
Dental provider number
Date of birth (mm/dd/yyyy)
IPA/MG number
Full-time student? (if over 18)  Yes  No
Existing patient?  Yes  No
Existing patient?  Yes  No
Doctor’s name
Dental provider name
First
First
Last
Last
Social Security number
Provider number
Dental provider number
Date of birth (mm/dd/yyyy)
IPA/MG number
Full-time student? (if over 18)  Yes  No
Existing patient?  Yes  No
Existing patient?  Yes  No
Doctor’s name
Dental provider name
First
First
Last
Last
Social Security number
Provider number
Dental provider number
Date of birth (mm/dd/yyyy)
IPA/MG number
Full-time student? (if over 18)  Yes  No
Existing patient?  Yes  No
 Son  Daughter
First
MI
 Medical
 Dental
 Vision
Last
Disabled?  Yes  No
 Son  Daughter
First
MI
 Medical
 Dental
 Vision
Last
Disabled?  Yes  No
 Son  Daughter
First
Last
MI
 Medical
 Dental
 Vision
Existing patient?  Yes  No
Disabled?  Yes  No
C15390 (2/10)
Employee enrollment application (for 51+ employees)
Page 4
Section 4 – Life insurance beneficiary
Primary beneficiary – Blue Shield Life will pay the proceeds to the primary beneficiary. If more than one person is named as primary beneficiary,
the proceeds will be distributed equally to those who survive the insured, unless otherwise specified in the % of benefits field.
First name First Name
Social Security number
MI
Last name Last Name
Relationship Relationship
% of benefits 100
Date of birth If known
Address At least City and State
City
State
First name
Social Security number
MI
Relationship
ZIP code
Last name
% of benefits
Date of birth
Address
City
State
ZIP code
Contingent beneficiary – Proceeds will be paid to a contingent beneficiary only if no primary beneficiary survives the insured.
First name
Social Security number
MI
Relationship
Last name
% of benefits
Date of birth
Address
City
State
ZIP code
Section 5 – Authorization
The following authorization section is to be signed by all employees applying for coverage with Blue Shield of California
or Blue Shield of California Life & Health Insurance Company (“Blue Shield Life”).
I agree: All information on this form is correct and true to the best of my knowledge and belief. I understand that it is the basis on which coverage may be
issued under the plan. I understand that if I have misrepresented or omitted any material fact that my coverage may be cancelled or my employer’s contract
rescinded. I further authorize my employer to deduct from my earnings the contribution (if any) required toward the cost of this plan.
I understand that coverage does not become effective until this and my employer’s application have been approved by Blue Shield of California/Blue Shield Life.
Date
Signature of employee_______________________________________________________________ Date _________________________
Type in Name
Print employee name _____________________________________________________________________________________________
Disclosure of Personal and Health Information
Blue Shield of California or Blue Shield of California Life & Health Insurance Company (collectively, “Blue Shield”)
understand the importance of keeping your and your dependents’ personal and health information private. Blue Shield
protects this information in electronic, written, and oral forms when used throughout our company. Blue Shield will not disclose this information without your authorization except as permitted by law.
For the purpose of administering your Blue Shield coverage, Blue Shield is permitted by state and federal law to obtain
your and your dependents’ health information from a healthcare provider, insurer, insurance support organization,
health plan, or your insurance agent. Also, by state and federal law, Blue Shield is permitted to disclose your and your
dependents’ health information to a healthcare provider, insurer, insurance support organization, health plan, or your
insurance agent.
A complete explanation of Blue Shield’s policies and procedures (“Notice of Confidentiality and Privacy Practices”) for
preserving the confidentiality of your personal and health information is available and will be furnished to you upon
request by calling the Customer Service Department or by accessing Blue Shield’s web site.
C15390 (2/10)
Employee enrollment application (for 51+ employees)
Page 5
Section 6 – Refusal of personal coverage
Complete if you, your spouse/domestic partner, or dependent(s) are refusing your employer’s Blue Shield of California/
Blue Shield Life health and/or dental plan coverage.
Employee name
Social Security number
Employer group name
Date of hire (mm/dd/yyyy)
Declining coverage for:
c I decline health plan coverage for myself, my spouse/domestic
partner, and all dependents.
c I decline health plan coverage for:
Reason for declining coverage:
c Covered by another employer’s health plan
(e.g., through your spouse/domestic partner)
Carrier name and ID number _____________________________
c My spouse/domestic partner only
c My children only
c My spouse/domestic partner and children
c The following dependents only:
__________________________________________________
__________________________________________________
c If dental offered, I decline dental coverage for myself, my spouse,
and all dependents.
c I decline dental plan coverage for:
c My spouse/domestic partner only
c My children only
c My spouse/domestic partner and children
c The following dependents only:
__________________________________________________
__________________________________________________
Group number
c Covered by an individual health plan
Carrier name _________________________________________
c Medicare, Medi-Cal, Healthy Families Program
c Covered by TRICARE
c No other employer health coverage
c Covered by another dental plan
Carrier name and ID number _____________________________
c Other ______________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
I acknowledge that the coverage available to me has been explained to me by my employer, and I know that I have every right to enroll in this
coverage, and I have decided not to enroll myself and/or my dependent(s), if any. I now decline to enroll myself, my spouse/domestic partner, and/or
my dependent(s) in my employer Blue Shield of California/Blue Shield Life health plan. I have made this decision voluntarily, and no one has tried to
influence me or put any pressure on me to decline coverage.
If I am declining enrollment for myself or my dependents because of other health coverage or because the employer stops contributing toward this
coverage, I acknowledge that I may be able to enroll myself and my dependents in this plan if I request enrollment within 31 days (60 days, if Medi-Cal or
Healthy Families coverage is lost) after my or my dependents’ other coverage ends, or after the employer stops contributing toward the other coverage.
In addition, if I acquire a new dependent as the result of marriage/domestic partnership, birth, adoption, or placement for adoption, I acknowledge that
I, and my dependents, may request enrollment in my employer’s health plan by applying for that coverage within 31 days of the marriage/domestic
partnership, birth, adoption, or placement for adoption. I also acknowledge that if I, or my dependents, become eligible for the Healthy Families or the Medi-Cal Premium Assistance Programs, I or my dependents may request enrollment in my employer’s health plan by applying for coverage within
60 days of the notice of eligibility for these premium assistance programs.
If I have indicated above that the reason for declining coverage for myself or my dependent(s) is coverage under another employer health benefit
plan, I acknowledge that, if I or my dependent(s) involuntarily lose coverage under the other employer health benefit plan, I must request enrollment
for myself and/or my dependent(s) in my employer health benefit plan within 31 days. Otherwise, I understand I may not enroll myself and/or my
dependents in my employer’s health plan until the earlier of the end of my employer’s next open enrollment period, or 12 months.
Signature of employee ______________________________________________________________________ Date __________________
Employers must retain a copy of any signed Refusal of Personal Coverage forms for their records.
C15390 (2/10)
Employee enrollment application (for 51+ employees)
Page 6
STATE OF CALIFORNIA
DEPARTMENT OF JUSTICE
BCIA 8016
(orig. 04/2001; rev. 01/2011)
REQUEST FOR LIVE SCAN SERVICE
Applicant Submission
AG545
Employee 11105.3 PC
ORI (Code assigned by DOJ)
Authorized Applicant Type
Employee
Type of License/Certification/Permit OR Working Title (Maximum 30 characters - if assigned by DOJ, use exact title assigned)
Contributing Agency Information:
Guided Discoveries, Inc.
17659
Agency Authorized to Receive Criminal Record Information
Mail Code (five-digit code assigned by DOJ)
P O Box 1360
Glenn Robison
Street Address or P.O. Box
Contact Name (mandatory for all school submissions)
CA
Claremont
City
91711-1360
State
ZIP Code
(909) 667-4600
Contact Telephone Number
Applicant Information:
Last Name
First Name
Other Name
(AKA or Alias) Last
First
Sex
Date of Birth
Height
Weight
Male
Female
Eye Color
Hair Color
Middle Initial
Suffix
Driver's License Number
Billing
Number 152782
(Agency Billing Number)
Place of Birth (City and State)
Social Security Number
Phone
Number
(Other Identification Number)
Home
Address Street Address or P.O. Box
City
Your Number:
Level of Service:
State
DOJ
ZIP Code
FBI
OCA Number (Agency Identifying Number)
If re-submission, list original ATI number:
(Must provide proof of rejection)
Original ATI Number
Employer (Additional response for agencies specified by statute):
Guided Discoveries, Inc.
17659
Employer Name
Mail Code (five digit code assigned by DOJ)
P O Box 1360
Street Address or P.O. Box
Claremont
CA
91711-1360
City
State
ZIP Code
+1 (909) 667-4600
Telephone Number (optional)
Live Scan Transaction Completed By:
Glenn Robison Date
Name of Operator
Guided Discoveries, Inc. Transmitting Agency
LP 4
LSID
ORIGINAL - Live Scan Operator
ATI Number
SECOND COPY - Applicant
Suffix
Amount Collected/Billed
THIRD COPY (if needed) - Requesting Agency
Guided Discoveries, Inc
PO Box 1360
Claremont, CA 91711
Dear Potential Employee,
I am pleased at the prospect of your becoming a fellow employee. Guided Discoveries is an outstanding
company and does important and rewarding work.
Because we work closely with children, and their safety and well-being are paramount, we have instituted
a Drug Free Workplace Program. A copy of the Company’s Drug and Alcohol Policy is contained in the
Employee Handbook which you have received or accompanies this memo. Compliance with the Policy is
a condition of employment with Guided Discoveries.
Because of the remote locations of our facilities, and because many of our employees come from outside
California, we have found it most efficient to have potential employees complete their pre-employment
drug testing at a “remote collection facility” near their home. There is no cost to you, but it does require
some initiative on your part, and will require a time line of up to two weeks. Follow the steps below:
1. Telephone Medtox Laboratories at 800.832.3244. Ask for the “Remote
Collection” department. Although Medtox Laboratories operates 24/7, the Remote Collection
department is open during normal business hours (Central time).
2. Identify yourself as a potential employee of Guided Discoveries, Account Number2422701.
3. The Medtox representative will locate a remote collection facility as close to you as possible,
4. usually during your initial telephone call.
5. The Medtox representative will send a sample collection kit to the collection site via UPS ground.
This may take more than a week, depending upon the site’s distance from Minneapolis.
6. The Medtox representative will indicate whether or not the collection site requires an appointment
for collection, or allows them on a walk-in basis. In either case, you will need to allow enough
time between your contact with Medtox and your testing appointment or visit to allow for delivery
of the collection kit to the collection site.
7. You should call the remote collection site in advance of your appointment to confirm their receipt
of the collection kit.
8. When you have completed the collection process, please let your hiring supervisor know.
If you have any questions or need any additional information, please contact your hiring supervisor. If
you have any difficulty in arranging for, or completing your pre-employment drug testing, you may call
me at 800.645.1423.
Sincerely,
Glenn B. Robison
Glenn B. Robison
Director of Support Services
DFWP Program Administrator
Program Class Descriptions
Below you will find descriptions of all the classes offered at AstroCamp. If you have questions about the classes,
please contact AstroCamp.
Daytime Classes
•
•
•
•
•
•
•
General Science and States of Matter
o Atmosphere & Gases: Learn about planetary atmospheric conditions and states of matter in our
most requested class. Hands-on experimentation allows students to learn about temperature, pressure,
density, and other gas properties.
Astronaut Training
o Microgravity: Learn about buoyancy and experience the challenge of constructing a mock satellite
in a neutrally buoyant environment. Swimsuit required.
o Expedition Valles Marineris: Simulate research on the surface of Mars with our interactive touchscreen computers and state-of-the-art rock wall. Learn about Mars and one of the larger canyons in
the solar system.
Electromagnetic Spectrum
o Electricity & Magnetism: Explore the properties of electricity and magnetism by experimenting
with magnets, static electricity, and electric current in a multitude of hands-on activities.
o Lights & Lasers: Learn about the physical properties of light by experimenting with lasers,
ultraviolet lights, spectrum glasses, an infrared camera, a phosphorescent wall, and more!
Rocketry
o Building & Launching Rockets (2 class periods): Learn about force and the laws of motion to
design and build a model rocket. Launch your own rockets powered by water and pressurized air.
Each student needs to bring a 2-liter soda bottle with a standard size opening.
Daytime Astronomy
o Planetarium: Enter our planetarium dome and learn about circumpolar rotation of the stars and
constellation myths. Learn about the size and scale of the universe, life cycles of stars, and
gravitational forces in our vortex room.
o Solar Studies: Use solar telescopes and lenses to view sunspots, prominences, and solar flares. Learn
about the properties of the sun, solar radiation, and solar energy.
Space Exploration
o Cosmic Lander: Learn about different types of space exploration vehicles and the challenges of
space travel. Design and build your own “cosmic lander” and test its ability to land on simulated
planetary surfaces.
o Remote Sensing: Learn about how we acquire information about objects without actually making
physical contact with them, and how we apply this information to our understanding of the universe.
Space Rocks
o Micrometeorites: Learn about meteors, meteorites, asteroids, and comets. Use magnets and
microscopes to collect and identify possible micrometeorites at AstroCamp. Simulate impacts with
our crater maker.
o Planets: Learn about the planets that make up our solar system and how scientists conduct research
to gain information on them. Learn about exoplanets, solar system scale, and kinesthetic astronomy.
ASTROCAMP TRIP PLANNING
Daytime Classes (cont.)
•
•
•
Hiking
o Day Hike (1 class period): Explore AstroCamp’s forest trails and learn about local flora, fauna, and
the history of the San Jacinto Mountains.
o Extended Day Hike (2 class periods): Take a longer and more in-depth hike through AstroCamp’s
forest trails.
o Full Day Hike (4 class periods): A full day of hiking and exploration around AstroCamp’s forest
trails. Learn about geology, remote sensing, and the natural history of the Idyllwild area. Lunch on
the trail will be included. For 5-day groups only.
Adventure Classes
o Initiatives: Build teamwork, trust, cooperation, and communication skills by participating in
problem-solving activities as a group. A prerequisite for any ropes course activities.
o Ropes Courses: Challenge your fears in these four high ropes elements. These physically and
mentally rigorous activities require trust, communication, and teamwork.
! Vinewalk: Balance on a tightrope while using hanging “vines” high in the trees.
! Powerpole: Climb up a telephone pole and lunge for a hanging tetherball.
! Sky Coaster: Swing through the air after classmates raise you up via a pulley system.
! Zipline: Climb up a cargo net then zip 700 feet across a meadow.
Extra Free Swim: An open swim time in our heated enclosed pool after lunch or dinner. A fee for lifeguards
will be applied.
Evening Classes
•
•
•
•
•
•
•
•
•
•
Space Night: Take a short night hike up to one of the Telescopes Viewing Areas in our signature
evening program. Learn how to use binoculars and telescopes to view deep sky objects. Each group gets
their own telescope station consisting of 2 telescopes and 5 binoculars. View images taken with our
digital telescope cameras (CCD). Activities include sensory awareness games, stargazing, and
constellation stories. Space Night is a combination of our Night Hike and Telescope Viewing programs.
Night Hike: Take a hour night hike, and play sensory awareness games
Telescope Viewing: Spend an hour learning to use binoculars and telescopes to view deep sky objects.
Astro Olympics: Compete in a series of carnival-type games in this fun and active program.
Free Swim: An open swim time in our heated enclosed pool. Lifeguards are provided at no additional
cost for the evening program option. Swimsuit required.
Interstellar Auction: Plan and bid for extrasolar planets and the materials needed to colonize them in
an exciting auction. Group cooperation and compromise is required for this thought-provoking activity.
Messier Madness: Learn about types of deep space objects. A group scavenger hunt will take place.
Please bring flashlights.
Space is Right: Students participate in AstroCamp’s version of the popular game show The Price is
Right! Take your best guess at answering questions about the size and scale of the objects in our
universe and our place in it.
School Night: If you have your own night program in mind we will provide audio/visual resources and
facilities. Please let us know which resources you will need so we can reserve them for you.
Astro Jeopardy (5-day groups only): Test your knowledge in this AstroCamp version of the popular
game show. This activity is designed to be a cumulative experience for 5-day groups.
Guided Discoveries, Inc.
Safety Communication Policy Dear Staff Member:
It is Guided Discoveries policy to maintain open communication between management
and staff on matters pertaining to safety. Your thoughts regarding safety are considered
important, and we encourage your active participation in our company safety.
Feel free at any time to express your safety concerns or suggestions individually to your
supervisor, or in writing on the safety suggestions for, which can be submitted
anonymously if you so desire. Be assured that all safety suggestions will be given serious
consideration and each will receive a response.
Also, the company will provide all current safety information and materials to the staff by
various means including ongoing training, news bullions, staff meetings and the use of a
bulletin board located in specific areas of your facility. Also, safety meetings may be
held periodically so that all employees have an opportunity to voice personal opinions
regarding safety and receive the training necessary.
Thanks for your continued efforts in keeping the camp safe.
Ross Turner
Ross Turner
Executive Director
Guided Discoveries, Inc.
GUIDED DICOVERIES, INC.
ASTROCAMP
STAFF HOUSING AGREEMENT
I understand that Guided Discoveries, Inc. is providing housing to the undersigned as a member
of Astrocamp staff for the mutual convenience of Guided Discoveries and myself. I understand
that I may be required to share a residence with one or more employees of the same sex.
Although every effort will be made to provide separate bedrooms for each employee, I may also
be required to share sleeping quarters. I further understand that if I am assigned an apartment in
which I am the only resident, Guided Discoveries may assign apartment-mates or possibly
roommates at a later date if necessary. I understand Guided Discoveries will make an effort to
accommodate staff requests, but the assignment of residences is at the sole discretion of Guided
Discoveries.
I agree to abide by all of Guided Discoveries’ housing policies set forth in the Employee
Handbook I have received. I specifically understand that illegal drugs and other governmentcontrolled substances of any kind, including, but not limited to marijuana, cocaine, and/or
hallucinogens are not permitted in my residence or on the Desert Sun Science Center campus. I
understand that cigarette smoking is not permitted inside dormitory apartments, in any public
buildings or in residences shared by non-smokers, and is only permitted in areas adjacent to the
residences or other designated areas. Candle or incense burning within the residence is not
permitted unless under supervised burning in a proper container. I understand that I will not
leave my residence without extinguishing the candle or incense.
I agree to be responsible for the daily cleaning, upkeep and simple maintenance of my residence
and outside areas. Major repairs will be the responsibility of Guided Discoveries or the owner of
the property. I further agree to be responsible for any damages caused either willfully or
accidentally by myself or any person under my control and I will report the need for repairs and
any damage to my supervisor immediately.
I understand that Guided Discoveries will provide a basically furnished residence, including a
bed, chairs, tables, refrigerator and basic kitchen utensils. Additional furnishings such as
televisions, VCRs, microwaves, radios, stereos and decorative items are my responsibility.
I agree not to make any alterations to my residence including but not limited to shelving,
painting, ceiling fixtures or wall hangings without the advance written approval of Guided
Discoveries. Any improvements so permitted will be at my sole expense.
I understand that Guided Discoveries wishes to make regular, unannounced health and safety
inspections of my residence and I consent to such inspections.
I understand that neither dogs nor cats are to be kept neither in my residence nor on the facility
premises. Fish are permitted, provided there is no conflict or objection by other co-habitants of
the residence.
I understand that unmarried cohabitation is not permitted throughout the facility and in my
residence. Married cohabitation must be discussed prior to first day of employment due to the
housing situation.
I agree that upon any termination of my employment with Guided Discoveries, I will vacate the
residence assigned to me within 24 hours unless otherwise agreed upon by the Astrocamp
Director. If I fail or refuse to vacate the premises within 24 hours, I agree to pay holdover
charge of $100.00 per day for each day or portion thereof, I occupy the premises. This sum may
be deducted from my wages due at termination. I will also reimburse Guided Discoveries for
any and all damages caused by my wrongful retention of the premises, including attorney’s fees
and costs incurred for any legal action required to restore possession of the premises to Guided
Discoveries.
Upon my departure from Astrocamp, I agree to leave the residence and furnishings in a clean and
orderly manner. I understand that the Astrocamp Director or his designee will inspect the
residence prior to my departure for cleanliness and damage. I understand and agree that a
deduction of up to $100.00 may be taken from my last paycheck for the cost of cleaning and/or
repair of damages to the residence caused by me or any person under my control.
I have read and understand this agreement and will abide by the terms and conditions set forth
herein.
Employee’s Signature
04/2011 MFP
Date
Guided Discoveries
343 North Harvard Avenue
Claremont, CA 91711
VERIFICATION OF COMPLETION OF INTRADERMAL MANTOUX
TUBERCULIN TEST REQUIREMENT
This is to certify that _________________________________________________ of
(Employees Name)
______________________________________ had a negative Mantoux Tuberculin
(Location)
on _____________________________.
(Date)
By: ________________________________
(Health Care Provider - please print)
_______________________________
(Signature)
Date: _________________________
Address of Provider: ____________________________________________________________
Please have this completed before your arrival to Astrocamp.
Thank you.
Guided Discoveries, Inc. Voluntary Disclosure and ICR Authorization & Release
Complete Legibly and Mail or Fax this Form to:
Guided Discoveries, Inc. Attn.: Glenn Robison
P O Box 1360 l Claremont CA 91711-1360
Facsimile: 909.625.7305
DO NOT RETURN TO YOUR HIRING SUPERVISOR
I hereby authorize Guided Discoveries, Inc. and its designated agents and representatives to conduct a
comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated
for employment purposes. I understand that the scope of the consumer report/investigative consumer report may include,
but is not limited to, the following areas:
Verification of social security number; current and previous residences; employment history including all personnel
files; education including transcripts; character references; credit history and reports; criminal history records from any
criminal justice agency in any or all federal, state, county jurisdictions; birth records; motor vehicle records to include traffic
citations and registration; and any other public records or to conduct interviews with third parties relative to my character,
general reputation, personal characteristics or mode of living.
I further authorize any individual, company, firm, corporation, or public agency (including the Social Security
Administration and law enforcement agencies) to divulge any and all information, verbal or written, pertaining to me to
Guided Discoveries, Inc. or its agents. I further authorize the complete release of any records or data pertaining to me which
the individual, company, firm, corporation, or public agency may have, to include information or data received from other
sources.
I hereby release Guided Discoveries, Inc., the Social Security Administration, and its agents, officials,
representatives, or assigned agencies, including officers, employees, or related personnel both individually and collectively,
from any and all liability for damages of whatever kind, which may, at any time, result to me, my heirs, family, or associates
because of compliance with this authorization and request to release. You may contact me as indicated below.
I understand this authorization automatically expires 90 days from the date executed below and that I have the right
to revoke the authorization at any time, provided I do so in writing.
Please print legibly. An incomplete or illegible form will delay processing and your hiring approval.
Print Name: _____________________________________________________________________________
(First)
(Middle)
(Last)
Position Applied For: _____________________________________ Facility: ________________________
Please provide complete address information for the last ten (10) years. Use addl. sheet if necessary.
Current Address: ________ ________________________________________________________________
(Mo/Yr)
(# / Street)
(City)
(State / Zip)
Previous Address: ________ _______________________________________________________________
(Mo/Yr)
(# / Street)
(City)
(State / Zip)
Permanent Mailing Address: _______________________________________________________________
(# / Street)
(City)
(State / Zip)
.
Social Security Number: ________________________________ Date of Birth: ______________________
Telephone Number: ______________________ Driver License Number / State:______________________
Email address:___________________________________________________________________________
Signature:______________________________________________________ Date:____________________
NOTICE TO CALIFORNIA APPLICANTS
Under California law, the consumer reports we order on you are defined as investigative consumer reports. These reports may
contain information on your character, general reputation, personal characteristics and mode of living.
I want to receive a free copy of any investigative consumer report requested on me by checking this box: 
Under section 1786.22 of the California Civil Code, you may view the file maintained on you by ADREM, Intellicorp or Vista
International Research during normal business hours. You may also obtain a copy of this file upon submitting proper identification and
paying the costs of duplication services, by appearing at ADREM, Intellicorp or Vista International Research in person or by mail. You may
also receive a summary of the file by telephone. The agency is required to have personnel available to explain your file to you and the agency
must explain to you any coded information appearing in your file. If you appear in person, a person of your choice may accompany you,
provided that this person furnishes proper identification.
(OVER)
DL  ___/___/___ by _____ — DFW/USCG  ___/___/___ — Bkgd  _______ ___/___/___ by ______
Please answer the following questions
1. Have you ever been convicted of any crime relating in any manner to children and/or your conduct with them?
 Yes  No
If yes, please explain: (Use a separate sheet if necessary.)
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
2. Have you ever been convicted of any crime including, but not limited to, those listed below and/or any crime similar in any
manner to those listed below?  Yes  No
 Indecent assault and battery on a child under fourteen
 Indecent assault and battery on a mentally retarded person
 Indecent assault and battery on a person who has attained the age of fourteen
 Rape
 Rape of a child under sixteen with force
 Assault with intent to commit rape
 Kidnapping of a child under sixteen with intent to commit rape
 Distribution and trafficking of narcotics or other controlled substances
 Intent to commit any of the above crimes
If yes, please provide the information below, using additional sheets if necessary.
Conviction
Date
Police Dept. / Agency
State & County
Crime and Charge
(i.e. burglary – felony)
Disposition
(i.e. Jail 5 Yrs; Community Svce.)
3. Have you ever been adjudged liable for civil penalties or damages involving sexual or physical abuse of children?
 Yes  No
If yes, please explain: (Use a separate sheet if necessary.)
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
4. Are you now or have you ever been subject to any court order involving sexual or physical abuse of a minor, including, but
not limited to domestic order or protection?  Yes  No
If yes, please explain: (Use a separate sheet if necessary.)
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
5.
Have your parental rights ever been terminated for reasons involving sexual or physical abuse of children?
 Yes  No
If yes, please explain: (Use a separate sheet if necessary.)
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
APPLICANT STATEMENT
I understand that Guided Discoveries may deny employment to any person who answers “Yes” to any one of questions 1-5. If
hired and Guided Discoveries later discovers circumstances that would indicate a “Yes” answer to any of the above
questions, employment may be terminated immediately.
I understand that the information provided on this form is subject to verification, which may include a criminal history check
and request from any Central Registry of child abusers.
I understand that Guided Discoveries may terminate employment or volunteer service of any person if that person is found,
regardless of when discovered, to:
1) have a history of complaints of abuse of a minor;
2) have resigned, been terminated or been asked to resign from a position whether paid or unpaid, due to
complaint(s) of sexual abuse of a minor; and/or
3) have falsified or omitted information in this disclosure statement.
Signature:______________________________________________________________ Date:_______________________________
GBR/Documents/Voluntary Disclosure Form.doc 201012131630