Camp Firefly Volunteer Registration
Saturday, Sept. 12 • Warriors’ Path State Park
Today's date (mm/dd/yyyy)
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Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of birth (mm/dd/yyyy)
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(mm/dd/yyyy)
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Emergency contact name
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Emergency contact phone number
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Please enter a valid phone number.
Format: (000) 000-0000.
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Job experience
Current or most recent employer
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Dates of employment
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Job title and/or duties
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Reason for leaving (if applicable)
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Education
Please describe the amount of education completed and any special skills/training
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Other information
Why are you interested in volunteering for Camp Firefly?
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Are there any specific talents or skills that you wish to share at camp?
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What experience (if any) have you had with childhood grief?
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Are you aware of any physical or mental disabilities which may hinder you from performing work as a Camp Firefly volunteer? If yes, please explain.
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Campers are divided into groups according to grade level. Please check the grade level with which you would prefer to work. We will take this into consideration when making volunteer assignments but may assign you to a different age group based on need.
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Pre-K
K-1
2-3
4-5
6-8
9-12
No preference
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References
Three references are required.
Reference 1 name
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First Name
Last Name
Reference 1 mailing address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reference 1 phone number
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Please enter a valid phone number.
Format: (000) 000-0000.
Reference 1 email
*
example@example.com
Reference 2 name
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First Name
Last Name
Reference 2 mailing address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reference 2 phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference 2 email
*
example@example.com
Reference 3 name
First Name
Last Name
Reference 3 mailing address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reference 3 phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference 3 email
*
example@example.com
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Acknowledgment
I hereby affirm that the information provided on this application is true and complete and to the best of my knowledge.
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I agree
I authorize a background investigation which may include education and employment history, criminal background check and reference check. I release from liability or responsibility all persons or corporations requesting or supplying information which may be sought in said investigation
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I agree
I further understand and acknowledge that if I am selected to participate in Camp Firefly, I will adhere to all rules, policies and procedures of the program and I shall not receive any compensation for my services nor will I be considered an employee of Ballad Health, any hospital which is a part thereof, or the Ballad Health Hospice program. I acknowledge and agree that I shall be providing services solely as a volunteer.
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I agree
Lastly, I hereby authorize the use of a photocopy of this acknowledgment by Ballad Health in conducting the investigation and obtaining the information I have herein authorized.
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I agree
Signature
Submit
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