Camp Independent Firefly - JC

Junior Counselor Application 2021

You are invited to participate in our 2021 Leaders in Training/Junior Counselor Program. This program is designed to build the skills necessary to become a future leader and counselor at Camp Independent Firefly this year or in the coming years.

We are inviting interested teenagers that are at least 16 years of age to attend.

Attached is the application for the 2021 Leaders in Training/Junior Counselor program scheduled for March 13th, 2021 from 10am-5pm Location TBD.

Please fill out the application completely no later than Friday February 20, 2021.

Note: To participate as a Junior Counselor at Camp Independent Firefly this summer, participants must be at least 17 years old, have submitted an online volunteer application and attend the March 13th training.

Unfortunately, there are limited Jr. Counselor spots at camp, attending this training does not guarantee a Jr. Counselor position at camp.

We look forward to seeing you!

Questions?

Call NHFNV at 702.564.4368 or Candlelighters at 702.737.1919.

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* 1. Junior Counselor Registration Form - Please enter your JCs information

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

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* 2. Phone Number

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* 3. Email Address

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* 4. Gender

Male

Female

Prefer not to disclose

Other

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* 5. Date of Birth

Date

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* 6. Age on 03/13/2021

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* 7. Please Check one

Patient

Sibling

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* 8. If Patient, please specify diagnosis

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* 9. Last Grade finished in school?

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* 10. Type of ID to be used at the airport (Reno Participants Only)

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* 11. Do you have any dietary restrictions? Please detail

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* 12. Parent 1/Guardian 1 Information

Name

Email Address

Phone Number

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* 13. Parent 2/Guardian 1 Information

Name

Email Address

Phone Number

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* 14. EMERGENCY CONTACT: If parents cannot be reached, whom should we contact?
Emergency Contact 1

Name

Phone Number

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* 15. Emergency contact's relationship to Junior Counselor

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* 16. Emergency Contact 2

Name

Phone Number

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* 17. Emergency contact's 2 relationship to Junior Counselor

CONSENT FOR MEDICAL TREATMENT
To Whom It May Concern:

In the event that I can not be present or reached by phone, I hereby authorize the Executive Director for the Nevada Chapter of the National Hemophilia Foundation or Candlelighters Childhood Cancer Foundation of Nevada, or his/her agent, to execute any and all documents including any necessary releases on my behalf that might be required by any medical facility to perform required emergency care on the basis of any accident or illness sustained or incurred by my minor child while attending the Leaders in Training/Jr. Counselor Program (LIT/JC).

I further agree that I, acting on behalf of myself or my minor child, do expressly and forever waive and release The Nevada Chapter of the National Hemophilia Foundation and Candlelighters Childhood Cancer Foundation of Nevada and all their respective officers, employees, agents or representatives from any and all liability for personal injuries or damages sustained, incurred or arising from participation at the LIT/JC Training.

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* 18. Signature of Parent/Guardian

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* 19. Guardians relationship to Junior Counselor

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* 20. Junior Counselors Insurance Information
If you have health and accident insurance coverage, list below

Name of Insurance Company

Policy Number

Certificate Number

Medicaid Number

Phone

Name of Policy Holder

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* 21. Address

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Camp Independent Firefly - JC

Junior Counselor Application 2021

Question Title

* 1. Junior Counselor Registration Form - Please enter your JCs information

Question Title

* 2. Phone Number

Question Title

* 3. Email Address

Question Title

* 4. Gender

Question Title

* 5. Date of Birth

Question Title

* 6. Age on 03/13/2021

Question Title

* 7. Please Check one

Question Title

* 8. If Patient, please specify diagnosis

Question Title

* 9. Last Grade finished in school?

Question Title

* 10. Type of ID to be used at the airport (Reno Participants Only)

Question Title

* 11. Do you have any dietary restrictions? Please detail

Question Title

* 12. Parent 1/Guardian 1 Information

Question Title

* 13. Parent 2/Guardian 1 Information

Question Title

* 14. EMERGENCY CONTACT: If parents cannot be reached, whom should we contact? Emergency Contact 1

Question Title

* 15. Emergency contact's relationship to Junior Counselor

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* 16. Emergency Contact 2

Question Title

* 17. Emergency contact's 2 relationship to Junior Counselor

Question Title

* 18. Signature of Parent/Guardian

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* 19. Guardians relationship to Junior Counselor

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* 20. Junior Counselors Insurance Information If you have health and accident insurance coverage, list below

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* 21. Address

* 14. EMERGENCY CONTACT: If parents cannot be reached, whom should we contact?
Emergency Contact 1

* 20. Junior Counselors Insurance Information
If you have health and accident insurance coverage, list below