Camp Empower Buddy Application

BUDDY APPLICATION
Camp Empower Location*
PERSONAL INFORMATION:
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of birth*
Year in School*
T-shirt Size*
EMERGENCY CONTACT INFORMATION:
Emergency Contact Name
Emergency Contact Phone Number
Relation to you
MEDICAL INFORMATION:
What is your insurance carrier?*
Group Number*
Policy Number*
EDUCATIONAL BACKGROUND:
College/High School, Degree, & Year Earned or Currently Enrolled*
Do you have any personal or professional experience with adoption or foster care? If yes, please explain.*
Do you have any personal or professional experience working with children?*
What are your areas of special interests or skills that might be interesting to a child or helpful with a camp project? (arts and crafts, outdoor games, etc..)*
Please give any information about the child you would feel most comfortable working with:*
What are your strengths?*
What are your weaknesses?*
Have you any history of abuse or neglect?*
Briefly describe what you hope to gain from helping with camp.*
BUDDY EXPECTATIONS AGREEMENT:

I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT.
Signature*

Clear
Date MM/DD/YYYY*
LETTERS OF RECOMMENDATION:

PLEASE INCLUDE 2 LETTERS OF RECOMMENDATION FROM SOMEONE OTHER THAN FAMILY MEMBERS:
Letter of Recommendation 1*

Cancelof
Letter of Recommendation 2*

Cancelof
Should be Empty:

BUDDY APPLICATION