August 1 st - 7 th 2015
Kimberly Henry BSRC-RRT, NPS, Ae-C
Camp Broncho Volunteer Coordinator
Applications are due by April 30, 2015 to:
By Mail:
Cook Children’s Medical Center
Camp Broncho / Kimberly Henry
Child Life Department
801 7 th Avenue
Fort Worth, TX 76104
By Fax: (682) 885-7480
Please contact Kimberly (Kimbo) Henry, Volunteer Coordinator, with questions:
Kimberly.Henry@cookchildrens.org
(940) 736-7624
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August 1st-7th
January 31, 2015: Volunteer Counselor Applications
Available @ www.campbroncho.com
Completed Applications Due April 30, 2015:
April - May 2015:
June 6, 2015
June 25, 2015
August 1, 2015:
August 2, 2015:
August 7, 2015:
Counselor Interviews Take Place (Previous counselors do not need to interview again.)
9:00 am – 12:00 pm @ Cook Children’s in Fort Worth
6:00 pm – 9:00 pm @ Children’s in Dallas
Counselors Report to Camp
Campers Arrive at Camp
Last day of an awesome camp!!!!!
Please contact volunteer coordinator with questions:
Kimberly (Kimbo) Henry
Cook Children’s Medical Center
Kimberly.Henry@cookchildrens.org
(940)736-7624
Website: www.campbroncho.com
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Name______________________________________________________________ Date ____/_____/______
Last First Middle
Permanent Address________________________________________________________________________
Street Apt. Number
__________________________________________________________________________________
City State Zip Code
Phone (_____)___________________(_____)___________________Email ___________________________
Home Cell
Social Security Number________-_________-________ Sex: Male Female ( circle one)
Driver’s License Number (____)__________________ Date of Birth_____/______/______
State
Please list previous residence(s) for the past 5 years including college:
Street address City & County State/Zip Code Dates of Residence
Current Employment__________________________________________________________________________
Company Name Position
Address_____________________________________________________________________________________
Street
________________________________________________________________(_____)_______________
City State Zip Work Phone
Educational Background (please check one) __ High School __ College __ Post Graduate
College/University Attended(ing) _______________________________________________________________
Degree(s) Earned ____________________________________________________________________________
If attending college please provide your college residence address ____________________________________
Street
___________________________________
City State Zip

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How did you hear about Camp Broncho? ___________________________________________________________
Have you volunteered at Camp Broncho before? Yes / No (circle one) If yes, for how many years? ___________
Are you able to volunteer for the entire week at camp (August 1-7, 2015)? Yes / No (circle one)
Have you ever volunteered for another camp at Camp John Marc? Yes/No (circle one)
If yes, which camp, and what year. _______________________________________________________________
Do you have experience with asthma? Yes / No (circle one) If yes, explain ______________________________
____________________________________________________________________________________________
Do you have experience working with kids? Yes / No (circle one) If yes, explain ___________________________
____________________________________________________________________________________________
Reason for wanting to be a volunteer ______________________________________________________________
____________________________________________________________________________________________
Community involvement ______________________________________________________________________
Most recent volunteer experience:
Dates Organization Duties Contact person/phone #
Are your volunteer hours required for another agency, service project, etc.? Yes / No (circle one)
If yes, name of agency ___________________________________ Hours Required ________________________
Do you have an age preference for the campers you will be working with? Yes / No (circle one)
If so, what age(s) and why? ____________________________________________________________________
Do you know any campers that are attending this year? Yes/No (circle one)
May we share your e-mail with fellow counselors to coordinate carpool, cabin items, etc.? Yes/No
(circle one)
T-shirt size: (Adult) Small Medium Large XL 2XL 3XL Other__________

Have you ever been convicted of a crime (other than a minor traffic violation)? Yes / No ( circle one)
If yes, please explain: __________________________________________________________________________
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Have you ever been convicted of any crime of violence against a minor? Yes_____No_______
Have you ever physically or sexually abused a child? Yes____ No _____
Has someone ever accused you of abusing a child? Yes______ No______
Volunteer Reference Form
References (3 required): One must be a past/present supervisor
Please give complete contact information, we will be contacting them
Name Address City, State, Zip Phone & E-Mail
Note:
-All first-time counselors will be required to participate in an interview with the volunteer coordinators. Returning counselors are not required to do so again and can fill out an abbreviated application.
-ALL COUNSELORS will be required to attend volunteer orientation session in
June. More information regarding meeting dates and times will follow.

2015 COUNSELOR HEALTH INFORMATION
Name Date
Current Physical Conditions: (please check all that apply)
 Epilepsy

Asthma
 Orthopedic Condition
 Diabetes

Heart Disease
 High Blood Pressure
In case of emergency (please list in order of importance):


Eczema
Migraines
1. _______________________ Phone # _______________ Relationship ___________
2. _______________________ Phone # _______________ Relationship ___________
Name of insurance company for health and accidents: ____________________________
Policy # ____________________ Group # __________________________
Doctor: ________________________________ Phone # __________________
Please document the last date of vaccination received:
Influenza _______
Diptheria, pertussis, tetanus (DPT) __________
Measles, mumps, rubella (MMR) __________
Have you had the chicken pox? _____________
When is the last date someone in your family had chicken pox? ____________________
Do you have any allergies? __________ If yes, please list.
________________________________________________________________________
What medications do you take routinely?
________________________________________________________________________
Please list any medications you will be bringing with you to camp:
_______________________________________________________________________
Do you have any physical condition that we should be aware of? If yes, please explain.
_______________________________________________________________________
Do you feel you can safely lift 50 pounds? __________
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CAMP STAFF/VOLUNTEER COUNSELOR
AGREEMENT AND RELEASE
In consideration for my being allowed to participate as a staff member/volunteer counselor of Camp Broncho at
Camp John Marc, Bosque County, Texas, during the week of August 1-7, 2015 .
I, _________________________, agree to release the Owner of Camp John Marc from any and all claims from personal injury, property damage or any other nature which might arise as a result of my use of Camp John Marc.
In addition, I shall refrain from instituting, pursuing or aiding any claim, demand, action or cause of action growing out of, or hereinafter to grow out of my use of camp. I understand that the signing of this release is a requirement of
Camp John Marc in order for Camp Broncho to have use of the Camp. This Agreement shall be binding upon me and my heirs, agents and assigns.
THIS IS A LEGAL RELEASE OF LIABILITY FORM. I HAVE READ THIS FORM
CAREFULLY AND HAVE HAD ALL QUESTIONS ANSWERED BEFORE SIGNING.
X ______________________________________ _____________________
(Signature) (Date)
X _____________________________________________
(Witness)
-------------------------------------------------------------------------------------------------------------------------------------------
Confidentiality Statement
Please read carefully before signing
I understand and agree that in the performance of my duties as a volunteer of Camp Broncho I must hold in strictest confidence any observations I may make or information I may hear regarding patients, patient families, or staff.
I verify that all of the information provided by me on this application is true, correct, and complete. I grant
Camp Broncho permission to verify this information in arriving at a volunteer decision. I understand that false or misleading statements or the omission of any information necessary to make this application complete may result in rejection of my application.
Applicant’s Signature Date

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AGENCY INFORMATION
Background Verification Release Form
Date
Contact Name
Agency’s Main Phone Number
Agency Name
APPLICANT INFORMATION:
Applicant Full Name (Last, First, MI)
Current Address
If Different, Address Prior 5 Years-City, State
Agency’s Fax Number
City
Maiden or Other Name(s) Used
State Zip Code
Social Security Number
Position Applied For
Date of Birth
Driver’s License Number
State Issued
 Male  Female Race  African American  American Indian  Anglo  Asian  Hispanic  Other
Gender
I hereby authorize VERI FYI and or its Service Provider to request and receive any and all background information about or concerning me, including but not limited to my Criminal History, Social Security Number Trace including a consumer report under the Fair Credit Reporting Act, 15 U.S.C 1681, Driving Record, Employment History, Military Background, Civil Listings,
Educational Background, Professional License from any Individual, Corporation, Partnership, Law Enforcement Agency, and other entities including my Present and Past Employers.
The criminal history, as received from the reporting agencies, may include arrest and conviction data as well as plea bargains and deferred adjudications and delinquent conduct as committed as a juvenile. I understand that this information will be used, in part, to determine my eligibility for an employment/volunteer position with this organization. I also understand that as long as I remain an employee or volunteer here, the criminal history check may be repeated at any time. I understand that I will have an opportunity to review the criminal history as received by client/agency and a procedure is available for clarification, if I dispute the record as received. I also understand that the criminal history could contain information presumed to be expunged.
I further release and discharge
VERI
FYI and their Service Provider and all of their Subsidiaries, Affiliates, Officers, Employees,
Contract Personnel, or Associates, from any and all claims and liability arising out of any request for information or records pursuant to this authorization, procurement of an investigative consumer report and understand that it may contain information about my character, general reputation, personal characteristics, and mode of living, whichever are applicable.
I understand that I have the right to make written request within a reasonable period of time to VeriFYI for additional information concerning the nature and scope of the investigation. I acknowledge that I have voluntarily provided the above information for employment/volunteer purposes, and I have carefully read and understand this authorization.
Applicant’s Signature Date
Applicant’s Printed Name Parent/Guardian’s Signature
(if under 18 years of age)