Volunteer Application

Personal Information

Select the week[s] you are applying for
First Name:
Last Name:
Birthday: yyyy-mm-dd
Gender:
Current Address:
City:
Province:
Postal Code:
Phone Number:
Alternate Number:
E-Mail:

Emergency Contact Information

Contact Name:
Relationship to Camper:
Phone Number:
Alt Number:

Medical Information

Health Care Number:
Providing Province:

Medically Diagnosed Allergies

Foods (specify):
Drugs (specify):
Other (i.e. Bee Stings):
My camper carries an Epipen: No Yes  for the following allergy:

Food Restrictions/Intolerances (if applicable)

Note: All dietary constrictions must be listed here prior to the start of the session. All special dietary needs will be shared with the kitchen staff. Please note Mill Creek Camp menus DO NOT cater to likes/dislikes. We have a balanced and varied menu that does include red meat, poultry and fish.
Select all that apply:  Vegetarian (no meat) Vegan (no meat/byproducts) Celiac Disease Lactose Intolerant

Medications

Are you bringing medications to camp? No Yes 
Please list ALL medications being sent to camp. Medications MUST be in original packaging. (Medication Name/Dosage/Administration Time/Reason for Taking)

Please answer the following questions:

Tetanus Immunization Date -must be current (Mandatory):
Are there any immunizations that you have chosen NOT to give yourself?:
Please indicate any significant medical conditions, physical limitations, or other concerns which will help us effectively care for you:  Anaphylactic Allergy Asthma Bed Wetting Concussions/Head Injuries Diabetes Ear/Nose/Throat Infection Epilepsy Migraine Headaches Recent Illness/Injury Mental Health Concerns
If any of the above were selected, please explain:
To the best of my knowledge, the information on this medical record is complete, current, and accurate: No Yes 

I give permission to self-administer the complimentary supplements that I have sent, under the supervision of a member of the Mill Creek Camp Health Care staff. No Yes N/A 

To the best of my knowledge, I do not have a communicable disease, and am physically able to participate in all Camp activities except as
indicated above. No Yes 

All medical problems or conditions requiring ongoing medical supervision or care have been fully noted. I give permission for this health information to be shared with the appropriate Camp staff and outside Medical Personnel as necessary. In the case of an emergency, I give permission for Camp staff to take whatever steps deemed necessary to ensure the safety and health of myself. This also allows permission for the Camp to contact my family physician/specialist. (Please inform your physician/specialist that you have given this authorization.)No Yes 

I agree to notify the Camp in writing if any changes occur in my health status, medications, or family
status between now and the start of the Camp session.  No Yes

Tell Us About Yourself

Why do you want to volunteer at Mill Creek this summer?

In which ways you would most like to serve during your time at camp?

Have you been a volunteer or staff at Mill Creek or another Camp Before?
 Yes No
If yes, was it a positive or negative experience? Why?

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