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Camp Personnel Forms and Application Procedures

Camp Personnel Forms and Application Procedures The following information is provided in question and answer format to familiarize ADA staff and
volunteers responsible for camp management with basic information regarding the forms and application
procedures for all camp personnel – both paid and volunteer. For additional information regarding the
hiring process, managing camp staff, termination and evaluation of camp personnel, please refer to the
Camp Implementation Tools found in the Programs Area of the Intranet. Why are there specific forms and procedures for camp personnel?
Specific information is needed from individuals seeking to work at Association sponsored camps in either
a paid or volunteer capacity. The information requested is necessary for risk management and to meet
minimum mandatory standards of the American Camping Association. The information provided by camp
personnel facilitates the recruitment, hiring, background search and payroll processes.
Is all of the information requested on each form mandatory?
No. Recognizing that there are a wide variety of camps within the Association, efforts have been made to
allow for the localization of camp personnel forms.
Any notations in red on camp forms are intended as instructions for those persons managing
camp and should be read and removed prior to actually using the forms. These notations will help
you identify the mandatory versus optional information on the form plus any specific information
that you must add to the application based on your particular camp and state. Examples:
If you do not have a CIT (counselors in training) program, you would eliminate the CIT category from the
list of choices under the question “What type of camp position are you seeking?”
If you do not need information about outdoor living skills or other skills listed in the Skills Inventory
because your site handles those program areas, you can eliminate those elements of the list.
Note: The Yearly Health Form is mandatory for ALL staff every year BUT on that form, there is a question
pertaining to yearly TB tests. You must know whether or not yearly TB tests are mandatory in your state
for camp staff. Only then can you determine if this is a mandatory question. If it is not mandatory, remove
the question from your application.
What about instructions for the person applying for a camp staff position?
Instructions for the applicant are placed before many items in black ink. Instructions are directed at “New
Applicant”, “Returning Staff” or “All Staff”. All instructions should be left on the form. Feel free to clarify
them.Do I have to use this application for my camp or can I use the one I currently have?
As long as all mandatory information is included in your application for returning and new staff, you are
free to use it. From a risk management perspective, you are encouraged to use this application.
Forms that must be used as presented (cannot be changed) are:
Human Resource Department’s Disclosure Statement and Waiver,
VoluntaryDisclosureForms I-9Camp Staff Code of EthicsW-4Provisional Letter of HireRES At Will (for payroll)ADA Summer Camp Enrollment Form (for payroll)Confidentiality AgreementHIPAA Form
The Application Form, Health History Form, Physical Exam Form, Cover Letter for Paid Staff and Cover
Letter for Volunteer Staff can be modified to meet local needs.

What if I have questions?
Email or call either Shana Funk atsfunk@diabetes.org or extension 3313 or Michelle Knight atmknight@diabetes.org or extension 2757. Camp Staff ApplicationPlease print or typeFollow the specific directions for each section or page. If not specified, please complete. (mandatory) Please check one: ______ Returning Staff Member ______ New Applicant (optional) T-shirt size:smallmediumlargex-large(mandatory) (mandatory) Date of Application: ___________Social Security Number: ________________(mandatory) Name: ___________________________________________________________________(optional)Name that you want to use at camp and on name tag (i.e. nick name): __________________(mandatory)Permanent Address: _________________________________________________________(optional) Current /college Address: _____________________________________________________
(if different from above)
Mail should be sent to: (Check One) _____Permanent Address ____ Current Address(mandatory) Daytime Phone Number: (_____) __________ Home Phone Number: ( ) _________(optional) Email Address:____________________________________________(List the positions for your camp; eliminate others) What type of camp position are you seeking?CounselorCounselor in Training/Junior CounselorCamp PhysicianCamp NurseCamp DieticianCamp Food ServiceWaterfrontProgrammingOther:(mandatory) Are you at least 18 years of age? ___ YES ___ NO*, if not state your age _____, DOB: _______
*[Camp Staff under the age of 18 must attach a copy of their valid work permit and a note signed by their
parent or guardian verifying their age.](mandatory) Do you have any physical or mental disabilities that might prevent you from performing the essential
functions of the position for which you are applying? ____ YES ____ NO
If YES, do you have specific suggestions as to how we could accommodate your mental or physical
disability? _____ NO _____ YES Describe: _____________________________________________________________________________(mandatory) Education: New Applicant: Complete Returning Staff: Changes or New Information Only Degree(s) AwardedYes/No YearMajorHigh School Diploma/GEDAABS or BAMA/MSDoctorate
Other(mandatory) Additional Professional Credentials that you hold: (CDE; R.Ph; RD; RN; MD, etc.)
_____________________________________ (mandatory) New Applicant: Complete Returning Staff: Changes/New Information only Past Two Years Employment: Place an X in front of any employer you do not want contacted.
Dates Employer Address Supervisor Phone # Position Held Reason For Leaving
Dates Employer Address Supervisor Phone # Position Held Reason For Leaving
(mandatory) New Applicant: Complete Returning Staff: New Information Only Relevant Camp, Volunteer, or Child Care Experience
DatesCamp or
OrganizationSupervisorAddressPhonePosition
Held (mandatory) New Applicants Only References (Give names/addresses of 3 persons not related to you who have knowledge of your
character, experience, and ability.)
NameAddressDay Time Phone
(include area code)
What contributions do you think camp can make in the lives of children with diabetes while at camp?(optional)_____________________________________________________________________________
_____________________________________________________________________________(optional)Age of Campers with whom you would prefer to work:____________________
(Optional) List and attach copies of current certification, licensure, or training (standard first aid, CPR, emergency
water safety, lifeguard training, etc.) you hold that you believe would be useful to you in the position for
which you are applying. (optional) Rate Your Knowledge: 1 = none 2 = some 3 = well versed 4 = consultant to others
____ADAExchangeSystem ____Exercise ____Insulin____BehaviorManagement ____HbA1c ____InsulinPump(s)____BloodTesting ____Hyperglycemia ____Ketoacidosis____CarbohydrateCounting ____Hypoglycemia ____Nutrition____DealingwithPeerPressure ____Injections ____SickDayCare____Diabetes Complications____Injection Site Rotation____Weight Management
Skill/Interest Inventory (optional) In the following list, put numeral “1” before the activities you can organize and teach as an expert; “2” for
those activities you can assist in teaching; and “3” for those which are your hobby.
Adventure/Challenge
Rappelling Climbing RopesCourses ObstacleCoursesNature AnimalsAstronomyBirdsConservationRocks & MineralsTrees & Shrubs InsectsCampcraftsForestryWeatherOrienteering OutdoorCooking FlowersHiking
Miscellaneous
HamRadio CampfirePrograms Computers EveningPrograms ElectronicsStorytelling
Dramatics
Directing PlaysSkits & StuntsCreative ArtsMagic
Music
Lead SongsPlay Instrument(s)List Instruments
Dancing
BalletFolkInterpretiveSocialSquareTap
Arts & Crafts
Basketry Ceramics Jewelry LeatherWork Journalism SketchingWeaving NatureCrafts Painting Photography Macrame MetalWork
Sports
SoccerBasketballFishing Hockey FieldGames HorsebackRiding SoftballTennisVolleyball Archery Badminton Baseball
Waterfront Activities
Canoeing Diving Rowing Sailing Swimming Kayaking WindSurfing Scuba Rafting Mandatory for All Medical Staff (New and Returning)
What license do you hold? _____________________________________
What states are you licensed in? _________________________________
Please attach a copy of your current license for the state in which camp occurs.
Has your license ever been revoked? _____ YES _____ NO
If YES, please explain:
____________________________________________________________________________________
__________
Have you ever been accused of, convicted of, or had deferred adjudication of medical malpractice?
___YES ___NO
If YES, please explain:
____________________________________________________________________________________
__________
Do you have malpractice insurance covering your service at camp? _____ YES _____ NOYearly Health Information All information on this form is mandatory and should not be changed except in reference
to TB testing. Mandatory YearlyAll StaffPlease complete this section yearly. Information on this form is to be provided by the camp staff
member for use by the Camp Director and Camp Medical Team.
Medical Insurance Company: ______________________________________________
Policy Number: ___________________________
Name of Policy Holder:___________________________________________________
In case of emergency, notify: _______________________________________________
Relationship to Staff Person:_______________________
Home Phone: (____)_______________Daytime Phone: (____)___________________
Health History: Place a checkmark by the following conditions if you have experienced them
within the past 12 months. ConditionConditionConditionSinusitisEar InfectionsUlcer or Colitis Fainting Stomachaches AnemiaHeart TroubleAlcohol or Drug
Use Dizziness Tuberculosis SexuallyTransmitted
Disease Diarrhea UrinaryTractInfection ShortnessofBreath Hepatitis,Type:Allergies, List:Medications, List: SeizureDisorder,Type:Other: ListOther: ListOther: List
Please describe any current health conditions, except for diabetes, requiring medication,
treatment, special restrictions or considerations while at camp:
____________________________________________________________________________
____________________________________________________________________________
Name of Primary Care Physician: _______________________________________
Phone Number of Primary Care Physician: (_____)_________________________ Immunizations: The American Diabetes Association does not require specific immunizations
for a person to work at camp; however, you must record the date of your last Tetanus shot.
Tetanus Shot Date: ___/___/________Check here if a tetanus shot has never been given. (You MUST check with your State Division of Epidemiology, TB Program to see if camp
staff are required to have this or not. If they are not, you are to delete it.) Very Important!! The Department of Public Health, Division of Communicable Disease / Epidemiology in ______
does require that a Tuberculin Test or Chest X-ray must have been performed within the 12
months prior to camp.
Date of Tuberculin Test or Chest X-ray: __/__/__

For Applicants/Returning Staff with Diabetes:
Please list how your diabetes is treated; all medications used by brand, type and dosage
including oral agents, insulins & all supplies for insulin pumps (manufacturer, model #, infusion
sets, etc)
__________________________________________________________________________________________________________________________________________________
____________________________________________________________________________
Do you recognize your own low blood sugars? ____ Yes ____ No ____ Not always
Name of Physician who treats your diabetes: ______________________________
Phone Number of Physician who treats your diabetes: (____)__________________
IN CASE OF MEDICAL EMERGENCY, I understand every effort will be made to contact
parents of staff or person designated as emergency contact. In the event that they/I cannot
respond, I hereby give my permission to the physician selected by the Camp Director and
medical team to hospitalize, secure proper treatment for and to order injection, anesthesia, or
surgery for me as named above.
__________________________________ ____/____/____Staff Member Signature Date __________________________________/____/____Signature of Parent for staff under the age of 18 DateI authorize investigation of all statements herein and release the camp and all others from
liability in connection with same. I understand that, if employed, I will be an at-will employee I
understand that untrue, misleading, or omitted information herein may result in dismissal,
regardless of the time of discovery by the camp.__________________________________ ____/____/____Staff Member Signature Date __________________________________/____/____Signature of Parent for staff under the age of 18 Date
All statements become part of any future camp staff’s personnel file. This form has been drafted to
comply with federal laws; however, the American Diabetes Association assumes no responsibility or
liability for use of this form.Mandatory for All Staffevery 2 yearsCamp Staff Physical Examination [to be completed by a licensed physician or nurse practioner] (This form meets ACA standards. If your current form meets the standards or you use the ACA
form, either is acceptable.) This medical examination must be completed within 24 months prior to the camp staff member’s reporting
date.
Date of Health Examination____/______/_____
Staff Member Name:__________________________________________________LastFirstMI
DOB___/___/___Sex: ____ Male ____ Female
The purpose of this examination is to determine that the camp employee is physically fit to engage in
strenuous camping activities with children with diabetes without harm to himself/herself and does not
have a contagious or infectious condition that could be conveyed to others. Indicates SatisfactoryX indicates Unsatisfactory – explain____ Posture____ Eyes____ Ears____ Extremities____ Pulse Rhythm____ Blood Pressure____ Menstrual
History/Genitalia____ Reactions to Medication____ Lungs____ Skin____ Hernia____ Teeth____ Tonsils____ Throat____ Abdomen____ Athlete’s Foot____ Nose ____ Heart _____ Allergy _____ Other:Explanation of Unsatisfactory Findings/Other:
___________________________________________________________________________________
___________________________________________________________________________________
Restricting Condition & Explanation:_______________________________________________________
____________________________________________________________________________________
Check below communicable diseases the staff member has been exposed to within the past 2 years:TuberculosisMeaslesWhooping CoughPolioChicken PoxRheumatic FeverDiphtheriaSmall PoxHepatitisType: ___________
Recommendation regarding staff member/patient: Full activityRestricted activityNo heavy lifting
Comments:_____________________________________________________________

______________________________________________________________________
______________________________________ _____________________________ :____/____/____
Print Name of Examining Physician: Signature of Examining Physician Date
Address:_____________________________________________________________________________
Area Code Phone #: (____) ____ - ____________Mandatory for all Staff Yearly – No changes can be made. Disclosure Statement
“By this document, The American Diabetes Association discloses to you that a
consumer report may be obtained for employment purposes as part of the pre-
employment background investigation and at any time during your employment. Please
sign below to signify receipt of the foregoing disclosure.”
________________________
Candidate Signature
________________________
ADA Staff Signature
________________________
DateWaiver
“This shall authorize the procurement of a consumer report by the American Diabetes
Association as part of the pre-employment background investigation. If hired, this
authorization shall remain on file and shall serve as an ongoing authorization for the
American Diabetes Association to procure consumer reports at any time during my
employment period.”
_________________________
Candidate Signature
_________________________
ADA Staff Signature
_________________________
DateNew Paid Staff Only No changes can be made to this form. RES AT-WILL AGREEMENT NOTE: American Diabetes Summer Camp staff are employees of RES for the purposes of payroll only.
In order to be paid, these personnel must sign the “AT WILL” agreement below. Only the American
Diabetes Association assesses job performance and chooses to retain or terminate the employment
relationship.The undersigned employee agrees and understands that he or she is being employed by Randstad Employment
Solutions on an at-will basis (for the purposes of payroll only) for a specific project or undertaking and that his or
her employment is limited to the duration of such project or undertaking. This employee further understands that
Randstad may terminate his or her employment at any time (if directed to do so by the American Diabetes
Association) without notice and with or without cause. The employee also understands and agrees that he or she is
an employee of Randstad for the Workers’ Compensation Laws. The employee also understands that Randstad shall
provide Workers’ Compensation coverage. Accordingly, in the case of bodily injuries, sustained by the employee
for which a Workers’ compensation is, or can be made, such Worker’s Compensation coverage provided by
Randstad shall be his or her exclusive remedy, and he or she shall have no right to make any other claims or bring
any action against Randstad or any of Randstad’s clients for such bodily injury.
The employee agrees and authorizes Randstad to deduct and withhold from the employee’s paycheck all Federal,
State and any other Local taxes as applicable. The employee also authorizes Randstad to deduct and withhold the
appropriate FICA taxes from the employee’s paycheck.
The employee further agrees that upon termination of the employment relationship, there will be no further
obligation or responsibility on the part of Randstad, or its clients, to the employee. Never the less, the employee
may apply for, and to the extent eligible, receive unemployment compensation from the appropriate state agency.
By the employee’s signature below, the employee acknowledges that he or she understands the above, and that he or
she voluntarily agrees to its terms.
_____________________________________ ____________________
PrintName Date
______________________________________
Signature
No changes can be made to this form. American Diabetes Association Summer Camp Employee Enrollment Form Please print in dark ink. Incomplete or illegible forms will not be processedPlease Check OneReturning Staff MemberNew Staff Member
Position /Title @ Camp__________________________________1. Social Security Number: ________________________________________2. Last Name: _____________________3. First Name: ________________4. Middle Initial: _____5. Permanent Mailing Address: _______________________________________6. City: ________________________7. State: ____________8 Zip Code:____________
9. Daytime Telephone: (______)________________ Evening Phone__________________
10. Local, city or township taxing authority (if applicable): ___________________ 11. Employee Signature: ______________________________________________ Alternate Paycheck Mailing Address:Mandatory Yearly
for All Paid Staff___________________________________ ____________________________________ Street Address / PO Box City, State, Zip code Camp Staff: Do not write below this line
Information below this line is to be completed by the authorized ADA camp representative only.
Camp:________________________ Area: _______________________Division:___________________
Payment Authorization
Amount to be paid: $______________/__________________________________________________ Write out in wordsDate(s) to Be Paid:__________________________________________________________________
Amount to be paid: $______________/________________________________________________ Write out in words
Date to Be Paid:_________________
Amount to be paid: $______________/_______________________________________________ Write out in wordsDate to Be Paid:__________________By signing below, you, the American Diabetes Association’s authorized representative, do hereby certify that the
above named individual has completed his/her work assignment and is entitled to receive the agreed upon stipend or
rate of pay.
_____________________________________ _____________________________________ __________
Print Name of Person Authorizing Payment(s)Signature DatePlease fax this form to RES at 516-677-0261 on the final day of camp or within 2 business days thereafter.
Payments to camp personnel will be made within 5 business days unless paperwork submitted is illegible, incomplete
or unsigned.Mandatory Yearly for All Staff Voluntary Disclosure Statement – Page 1 No changes to this form. All camp personnel must complete this form each year. For camp personnel under 18, the form must be signed by the
staff member and a parent or legal guardian. Incomplete, unsigned or illegible forms will not be processed resulting in
significant delays. Please print in dark ink.For ADA Staff Use ONLY: Please complete
Camp Name: Area: Division Name of ADA staff member submitting this form:Staff Member’s Phone #Staff Member’s FAX #Staff Member’s Email Address
CHECK ONE ONLY RETURNING STAFF MEMBERNEW STAFF MEMBER Check all that Apply for Returning Staff Member: Check All that Apply for New Staff Member: Criminal History (mandatory) – 1 year/1 Name
only Criminal History (mandatory) – 7 years Drivers License Drivers License Professional License Verification Applicant: Please complete remainder of form. Please print in dark ink.
Name: ______________________________________________________________________
All Maiden/Former Names or Alias: __________________________________________________
Date of Birth _______/________/_______ SSN: ___ ___ ___ - ___ ___ - ___ ___ ___
Home Address: ________________________________________________________________(street)_____________________________________________________________________________(city/town) (state) (zip)
Have you ever been convicted of a felony? YES NO
Have you moved in the last year? YES NO Have you been married in the last year? YES NO
Have you moved in the past seven years? YES NO
Have you been married/divorced/remarried in the last seven years? YES NO
Gender: ___ Male___ FemaleMarital Status: _____ Married _____ Single
Driver’s License Search: Complete ONLY if You Will be Driving on Behalf of Camp: If you have been cited,
ticketed, involved in an accident or had your license revoked in the past three years, you cannot drive on behalf of camp.
Please inform your ADA staff contact.
Driver’s License Number: ______________________ State: ________ Expiration Date: _____________________
Medical License Verification: For New Medical Staff ONLY; Not Returning Medical Staff

License Number: _____________________Type: ___________________ State(s): ___________
In applying for a camp position, the information that I have furnished on this form is subject to verification, which may
include a criminal history check and request from any central registry of child abusers.
VERY IMPORTANT! This form CANNOT be processed without the Applicant’s Signature.
Signature: ______________________________________________Date: ________ Parent/Legal Guardian Signature: ____________________________Date:________ADA staff person retains this page in local camp files. Do not send to RES. Voluntary Disclosure Statement- Page 2New Applicants hired within 30 days before camp or Returning Staff returning form(s) within 30 days of camp must
complete.
Have you ever been convicted of any crime of violence against minors, including but not limited to those listed
below? (circle YES or NO) YES NO Indecent assault and battery on a child under the age of 14 years of ageYESNOIndecent assault and battery on a mentally retarded personYESNOIndecent assault and battery on a person 14 years of age or olderYESNORape YESNORape of a child under 16 years ofagewithforce YESNOAssault with intent to commit rapeYESNOKidnapping of a child under 16 years of age with intent to commit rapeYESNODistribution and trafficking of narcotics or other controlled substancesYES NOIntent to commit any of the above crimesYESNOOther YESNOIf you answered yes to any of the above, please explain: (use a separate sheet if necessary)
______________________________________________________________________________________________
______________________________________________________________________________________________
Have you ever been adjudged liable for civil penalties or damages involving sexual or physical abuse of
children? ____Yes ____ No, If yes, please explain.___________________________________________________________________________________________
___________________________________________________________________________________________
Are you subject to any court order involving sexual or physical abuse of a minor, including but not limited to a
domestic order or protection? _____Yes _____No If yes, please explain.
____________________________________________________________________________________________
____________________________________________________________________________________________
Have your parental rights ever been terminated for reasons involving sexual or physical abuse of children?
_____ Yes _____ No If yes, please explain.
________________________________________________________________________________________
________________________________________________________________________________________
I understand that:
The camp may deny employment to any person who answers any of the questions above in the affirmative.
In applying for a camp position the information that I have furnished on this form is subject to verification, which may
include a criminal history check and request from any central registry of child abusers.
The camp may terminate employment or voluntary service of any person:Found to have a history of complaints of abuse of a minor and/orFound to 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.VERY IMPORTANT! This form CANNOT be processed without the Applicant’s Signature.

Signature: ______________________________________________________________Date _______
Parent/Legal Guardian Signature:____________________________________________Date:________Mandatory Yearly - All StaffCamp Staff Code of Ethics While information can be added, no deletions are to be made. This document should be read, signed and returned by all camp staff – paid and unpaid.
Protection of Campers: Campers are not to be left alone without the supervision of at least two adults at any time. Proper supervision mayprevent potential injury and abuse. Camp personnel will never be alone with campers or an individual camper. Camp personnel will not abuse campers including: Physical abuse: strike, spank, shake, slap Verbal abuse: humiliate, degrade, threaten, use profanity Sexual abuse: including inappropriate touching, or display Mental abuse: hazing, negative manipulation, teasing or bullying Camp personnel will treat with confidence and respect the personal information they have learned from or aboutcampers, subject to the policies on reporting abuse and neglect. Camp personnel will treat campers of all ethnic, religious, and cultural backgrounds with respect and consideration. Camp personnel will report any suspicions of abuse or neglect to the appropriate camp leadership (Camp Director orMedical Director) immediately in compliance with state reporting regulations. Camp personnel will use positive guidance techniques including redirection, anticipation, and/or elimination ofpotential problems, positive reinforcement, support and encouragement rather than competition, comparison,
criticism, or humiliating discipline techniques. Camp personnel will report any incident or accident immediately to the Camp Director and Medical Director.
Staff Protection/Conduct
Camp personnel will portray a positive role model for campers, including but not limited to, maintaining an attitude ofrespect, loyalty, patience, honesty, courtesy, tact, and maturity. Camp personnel will not use profanity or discuss adult subject matter in the presence of campers. Camp personnel will dress appropriately for camp (guidelines will be discussed during staff training). Camp personnel will not use, possess, or be under the influence of alcohol or illegal drugs while at camp or camptraining events. Camp personnel are prohibited from having firearms or other weapons while at camp. Camp personnel will comply with the outlined activities and expectations of their defined jobs at camp andparticipate in all required activities prior to camp (i.e., camp training). Camp personnel must be willing and prepared to assist campers in meeting daily personal needs. Camp personnel must accommodate and be sensitive to the developmental differences and abilities of individualcampers. Camp personnel will not offer to or accept gifts of goods or money from campers or their families. Camp personnel will not abuse, steal from, or show disrespect to their fellow staff, campers, or camp/personalproperty. Camp personnel will adhere to the outlined camp policies, procedures, and standards.(continued) Camp personnel will agree to all criminal and other background check information requested of them and must meetqualification standards established by the camp.
I understand and agree to adhere to all expectations and rules established by the camp, and the American Diabetes
Association as explained above. I understand that failure to comply may result in dismissal.
Signature: _____________________________________ Date: ______________
If camp staff member is under the age of 18 the signature of his/her parent or guardian must also be provided below:
Signature: ____________________________________ Date: ______________AMERICAN DIABETES ASSOCIATIONAUTHORIZATION TO DISCLOSE PERSONAL HEALTH INFORMATION HIPAA (Health Insurance Portability and Accountability Act)Staff Member Name: __________________________________________________________
Staff Member Date of Birth ___________________________________________________
Name of Custodial Parent /Legal Guardian if staff member is under 18_________________________________________________________I hereby authorize the American Diabetes Association (ADA) to release my/my child’s personal health information as
described below:
The purpose of this disclosure is to promote the ADA camp program, publicize the ADA camp program, and/or fund-
raise for the American Diabetes Association:
The PHI to be disclosed is limited to the following:
[ ] Staff Member’s photograph or likeness
[ ] Other: (specify_______________________)
The PHI may be disclosed as part of the American Diabetes Association’s marketing efforts, including but not limited to,
mailing list development for camp, a brochure promoting camp or other educational program, or fundraising events of
the American Diabetes Association.
Expiration date: This Authorization shall expire on December 31, 2014.
Right to Revoke: I understand that I have the right to revoke this Authorization at any time by giving ADA written notice
of the revocation. I understand that any revocation will not apply to any disclosure that has already been made in
reliance upon this authorization. I understand that I have the right to refuse to sign this Authorization and that my refusal will not affect my/my child’s
ability to receive treatment, get payment for treatment, or attend camp.
I understand that I will be given a copy of this signed Authorization.
A copy of this document is valid as an original. The original is not required to be shown.
_______________________________ ___________________________________________Name of Staff Member (print)Signature of Staff MemberDate
________________________________ ___________________________________________Parent’s/Legal Guardian’s Name if Staff Parent’s/Legal Guardian’s SignatureDateMemberis under 18. (print)Confidentiality AgreementAccess and Use of Personal Health InformationUnder the Health Insurance Portability and Accountability ActBy American Diabetes Association Camp Staff and Volunteers
Staff Member Name: ________________________________________
Staff Member Date of Birth ___________________________________
_________________________________________________________
Name of Custodial Parent /Legal Guardian if staff member is under 18I, ____________________, understand that I will have access to and will use personal health information (“PHI”) of
campers, fellow staff members and volunteers, while serving at or in preparation for an ADA camp program.My camp position/duties that involve PHI may include:• Provision of medical management for campers and camp personnel to ensure their physical well being and safety• Provision of food service and nutrition counseling for campers and camp personnel to ensure their physical wellbeing• Provision for the well being and safety of campers in the common living areas (cabins and tents) relative to co-morbidities, diabetes treatment plans, food allergies, other allergies and behavioral/psychological/social issues.• Provide for the safety and well being of campers and camp personnel who will participate in the camp program.
I agree to safeguard PHI and make sure that it is not used in an unauthorized way or given to any unauthorized person
or entity.
I hereby agree that I will not copy, record, disseminate, share, use or disclose any PHI beyond my camp position/duties.I understand that I have the right to refuse to sign this Confidentiality Agreement and that my refusal will disqualify me
from serving in any capacity with the ADA camp program that would provide access to personal health information in
written, electronic or verbal form.
________________________________________________________________Name of Staff Member (print)Signature of Staff MemberDate
_____________________________ __________________________ __________Parent’s/Legal Guardian’s Name ifParent’s/Legal Guardian’s Signature DateStaff Member is under 18. (print)Provisional Letter of Hire – Paid Staff -MandatoryDate
Name
Address
Address
Dear:
I am pleased to make a provisional offer of employment to you for the position of _________________ working in the
________________ Division of the American Diabetes Association at Camp __________________. Your salary will be
$_________ for the period _____ / ____ / 2004 through ____ / ____ / 2004. If for any reason you do not work all of
these days, your salary will be adjusted accordingly. Your position is temporary and is expected to end on the last day of
camp. As a temporary employee, you are not eligible for benefits. Medical staff will receive personal medical mal-
practice coverage through a nationwide policy. Provided all required paperwork is received in time and background
checks are satisfactory, your starting date will be _________________. This letter in no way intends to create a contract
of employment for any specific length of time.
Submission of Paperwork: Your required paperwork must be complete and received in the American Diabetes Association office by [InsertDeadline Date]. If your paperwork has not been received by [Insert Deadline Date], your employment status will be changed tovoluntary and you will not be paid. No paperwork will be accepted at camp on opening day In accordance with American Camping Association accreditation standards, local, state, and federal laws, you willnot be allowed on camp property if your paperwork is incomplete. Return the required copies of identification with your I-9 form. (This establishes your identity and eligibility to work inthe United States.) If these documents require your signature,(such as your social security card) sign before
submitting with your paperwork Sign and date all forms where indicated.
At the conclusion of your assignment, your employment paperwork will be processed and a paycheck for the full period
of your employment will be issued. It may take four weeks from your last day of employment to receive your check.
Welcome to the American Diabetes Association staff of Camp ____________. I look forward to working with you.
Sincerely,
Camp Coordinator
______________________________________ ____________________
Camp Staff Member SignatureDateProvisional Letter of Hire – Volunteer Staff - MandatoryDate
Name
Address
Address
Dear:
I am pleased to make a provisional offer to you for the position of ___________________, which is a volunteer staff
position working in the ______________ Division of the American Diabetes Association at Camp ________________.
There is no salary associated with this position. Medical staff will receive personal medical mal-practice coverage
through a nationwide policy. You will serve in this position for the period from __/__/2004 through ___ /__/2004. Your
position is temporary and is expected to end on the last day of camp. As a temporary employee, you are not eligible for
benefits. Provided all required paperwork is received in time and background checks are satisfactory, your starting date
will be _________________. This letter in no way intends to create a contract of employment for any specific length of
time.

Submission of Paperwork: Your required paperwork must be complete and received in the American Diabetes Association office by [Insert Deadline Date]. No paperwork will be accepted at camp on opening day. In accordance with American Camping Association accreditation standards, local, state, and federal laws, you will not be allowed on camp property if your paperwork is incomplete. Sign and date all forms where indicated.
We look forward to working with you. Welcome to the staff of Camp ____________________.
Sincerely,
Camp Director
______________________________________ ____________________
Camp Staff Member SignatureDateCover Letter – PaidStaff
Dear Returning and Prospective Year 2004 Camp Staff:
Thank you for your interest in working with the American Diabetes Association to provide camp this summer
for children with diabetes.
Camp Staff will arrive at camp on ____________________. Camp will end for staff on_____________
Campers will arrive on ___________________ and leave on _____________________._
Training for camp staff will be held on ____________________ at _____________________________.
Please read the following information carefully. If you want to join our team, you must complete and return all
forms no later than ______________________. In accordance with American Camping Association
accreditation standards, local, state, and federal laws, you cannot be allowed on camp property if your
paperwork is incomplete.Please be advised that references, employment verification and background searcheswill be done on all staff. Staff selection and the number of staff selected is contingent upon timely receipt of
all paperwork, satisfactory background clearances AND the number, age and gender of children attending
camp.
Complete, Sign, Date & Return These Forms to: (Put appropriate Name & Address.) Camp Staff Application
Provisional Letter of Hire - 2 copies; Return One. Keep one.
Camp Staff Physical Exam Form – To Be Completed by Your Physician. Good for 2 years.
[Returning Staff: Call the ADA office to check expiration date.]
Camp Staff Yearly Health History Form –All Staff must complete yearly.
Voluntary Disclosure Form
Human Resources Disclosure & Waiver Statement
Camp Staff Code of Ethics
W-4
I-9 – plus a copy of 1 document from List A or one from List B and C (see back of I-9)
ADA Camp Staff Enrollment Form
At Will Agreement
Authorization to disclose personal health information (HIPAA)
Confidentiality Agreement
For Your Information Only:
Camp BrochureJob DescriptionCamp Personnel PoliciesFair Credit Reporting Act Information Sheet.
If you have questions, please call __________________ at _________________.
Sincerely
Camp ChairpersonCover Letter Volunteer Staff
Dear Returning and Prospective Year 2004 Camp Staff:
Thank you for your interest in working with us to provide camp this summer for children with diabetes.
Camp Staff will arrive at camp on _________________. Camp will end for staff on _______________.
The campers will arrive on ___________________ and leave on _________________.
Training for camp staff will be held on _______________ at _________________________________.
Please read the following information carefully. If you want to join our team, you must complete and return all
forms no later than ______________________. In accordance with American Camping Association
accreditation standards, local, state, and federal laws, you cannot be allowed on camp property if your
paperwork is incomplete. Please be advised that references, employment verification and background searcheswill be done on all staff. Staff selection and the number of staff selected is contingent upon timely receipt of
all paperwork, satisfactory background clearances AND the number, age and gender of children attending
camp. Specific instructions appear on each form.
Complete, Sign, Date & Return These Forms to: Put Appropriate Name & Address Camp Staff Application
Provisional Letter of Hire- 2 copies; Return One – All Staff
Camp Staff Physical Exam Form – To Be Completed by Your Physician. Good for 2 years. Returning staff should call the ADA office to check expiration date on your form.
Camp Staff Yearly Health History Form –All Staff must complete yearly.
Camp Staff Code of Ethics
Voluntary Disclosure Form
Human Resources Disclosure & Waiver Statement
Authorization to disclose personal health information (HIPAA)
Confidentiality Agreement
For Your Information Only:
Camp Brochure (if applicable)Job DescriptionCamp Personnel PoliciesFair Credit Reporting Act Information Sheet.
If you have questions, please call __________________ at __________________.Sincerely
Camp Chairperson A Summary of Your Rights Under the Fair Credit Reporting Act The federal Fair Credit Reporting Act (FCRA) is designed to promote accuracy, fairness, and privacy of
information in the files of every "consumer reporting agency" (CRA). Most CRAs are credit bureaus that gather
and sell information about you -- such as if you pay your bills on time or have filed bankruptcy -- to creditors,
employers, landlords, and other businesses. You can find the complete text of the FCRA, 15 U.S.C. §§1681-
1681u. The FCRA gives you specific rights, as outlined below. You may have additional rights under state law.
You may contact a state or local consumer protection agency or a state attorney general to learn those rights.• You must be told if information in your file has been used against you. Anyone who uses informationfrom a CRA to take action against you -- such as denying an application for credit, insurance, or
employment -- must tell you, and give you the name, address, and phone number of the CRA that provided
the consumer report.• You can find out what is in your file. At your request, a CRA must give you the information in your file,and a list of everyone who has requested it recently. There is no charge for the report if a person has taken
action against you because of information supplied by the CRA, if you request the report within 60 days ofreceiving notice of the action. You also are entitled to one free report every twelve months upon request ifyou certify that (1) you are unemployed and plan to seek employment within 60 days, (2) you are on welfare,
or (3) your report is inaccurate due to fraud. Otherwise, a CRA may charge you up to eight dollars.• You can dispute inaccurate information with the CRA. If you tell a CRA that your file contains inaccurateinformation, the CRA must investigate the items (usually within 30 days) by presenting to its information
source all relevant evidence you submit, unless you dispute is frivolous. The source must review your
evidence and report its findings to the CRA. (The source also must advise national CRAs -- to which it has
provided the data --of any error.) The CRA must give you a written report of the investigation, and a copy
your report if the investigation results in any change. If the CRA's investigation does not resolve the
dispute, you may add a brief statement to your file. The CRA must normally include a summary of your
statement in future reports. If an item is deleted or a dispute statement is filed, you may ask that anyone
who has recently received your report be notified of the change.• Inaccurate information must be corrected or deleted. A CRA must remove or correct inaccurate orunverified information from its files, usually within 30 days after you dispute it. However, the CRA is not
required to remove accurate data from your file unless it is outdated (as described below) or cannot be
verified. If your dispute results in any change to your report, the CRA cannot reinsert into your file a disputed
item unless the information source verifies its accuracy and completeness. In addition, the CRA must give
you a written notice telling you it has reinserted the item. The notice must include the name, address and
phone number of the information source.You can dispute inaccurate items with the source of the information. If you tell anyone -- such as a
creditor who reports to a CRA -- that you dispute an item, they may not then report the information to a CRA
without including a notice of your dispute. In addition, once you've notified the source of the error in writing, it
may not continue to report the information if it is, in fact, an error.• Outdated information may not be reported. In most cases, a CRA may not report negative informationthat is more than seven years old; ten years for bankruptcies.• Access to your file is limited. A CRA may provide information about you only to people with a needrecognized by the FCRA -- usually to consider an application with a creditor, insurer, employer, landlord, or
other business.• Your consent is required for reports that are provided to employers, or reports that contain medical information. A CRA may not give out information about you to your employer,or prospective employer,
without your written consent. A CRA may not report medical information about you to creditors, insurers, or
employers without your permission.• You may choose to exclude your name from CRA lists for unsolicited credit andinsurance offers.Creditors and insurers may use file information as the basis for sending you unsolicited offers of credit or
insurance. Such offers must include a toll-free phone number for you to call if you want your name and
address removed from future lists. If you call, you must be kept off the lists for two years. If you request,
complete, and return the CRA form provided for this purpose, you must be taken off the lists indefinitely.• You may seek damages from violators. If a CRA, a user or (in some cases) a provider of CRA data,violates the FCRA, you may sue them in state or federal court.The FCRA gives several different federal agencies authority to enforce the FCRA: FOR QUESTIONS OR CONCERNS REGARDING PLEASE CONTACT
CRAs, creditors and others not listed belowFederal Trade CommissionConsumer Response Center- FCRA Washington, DC 20580 * 202-326-3761
National banks, federal branches/agencies ofOffice of the Comptroller of the Currencyforeign banks (word "National" or initials "N.A."Compliance Management, Mail Stop 6-6appear in or after bank's name)Washington, DC 20219 * 800-613-6743
Federal Reserve System member banksDivision of Consumer & Community Affairs(except Federal Reserve Board national banks,Washington, DC 20551 * 202-452-3693 and federal branches/agencies of foreign banks)
Savings associations and federally charteredOffice of Thrift Supervisionsavings banks (word "Federal" or initialsConsumer Programs"F.S.B." appear in federal institution's name)Washington D.C. 20552* 800- 842-6929
Federal credit unions (words "Federal CreditNational Credit Union AdministrationUnion" appear in institution's name)1775 Duke Street Alexandria,VA22314*703-518-6360
State-chartered banks that are not membersFederal Deposit Insurance Corporationof the Federal Reserve SystemDivision of Compliance & Consumer Affairs Washington,DC20429*800-934-FDIC
Air, surface, or rail common carriers regulated byDepartment of Transportationformer Civil Aeronautics Board or InterstateOffice of Financial ManagementCommerce CommissionWashington, DC 20590 * 202-366-1306
Activities subject to the Packers and StockyardsDepartment of AgricultureAct,1921 OfficeofDeputyAdministrator-GIPSA Washington,DC20250*202-720-7051

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