January 1, 2017 Dear Prospective SunSibs Staff,

Thank you for your interest in being a member of the SubSibs staff. We are very excited for SunSibs Carnival 2017. SunSibs will be held May 26-29, 2017 at Camp Puh'tok in Monkton Maryland.

The Department of Volunteer Services of Johns Hopkins Hospital will be handling all SunSibs applications. All staff must submit references. In addition to the references, fingerprinting is required for all new staff members. Please go to your local CJIS office to get fingerprints completed. The account number needed is 1000001995. You can find an index of local CJIS sites that could provide fingerprinting services here: http://www.dpscs.state.md.us/publicservs/fingerprint.shtml

In the past, returning staff have been able to submit their applications past the due date and then proceed to attend camp. This is no longer an option. All SunSibs staff applications are due NO LATER than Saturday March 4, 2017. Immunizations Records (Page 5), General Health History (Page 6) must be returned NO LATER than April 15, 2017 in order to have Volunteer Services at Hopkins process your records. If your application is turned in after this time, even for returning staff, you will not be considered for a position at camp (NO EXCEPTIONS).

Enclosed you will find information listing requirements needed to become a SunSibs Volunteer. When completing the application, you can either email your completed application to tmbeam83@gmail.com or send the completed application to:

Johns Hopkins Sun Sibs C/O Tommy Beam

PO Box 470 Hanover, PA 17331

Once we have received your application, the Department of Volunteer Services will process your information. The Staff Director will contact you to schedule an interview if you are considered a new staff. Once you have secured a staff position, you must attend camp orientation, date and time to be determined. During orientation, you will learn about the history of Camp Sunrise and SunSibs as well as camp policies and procedures. This is mandatory for all returning and new staff! We will send out more information as we approach camp.

We are also recruiting new volunteers. Please tell a friend about this wonderful program. For additional applications, please contact the staffing director or visit our website: www.hopkinsmedicine/campsunrise We are looking forward to seeing you at camp for SunSibs Carnival 2017 Sincerely, Tommy Beam Kasey Carroll Staff Director Camp Director tmbeam83@gmail.com kcarro4@gmail.com

Volunteer Application Johns Hopkins University

Pediatric Oncology May 26th -29th 2017

Due March 4, 2017 General Information (please print)

Name: Male Female

Address: E-mail:

City: State: Zip:

Home Phone: Work Phone:

Cell Phone: Date of Birth:

Are you a U.S. Citizen? Yes No If no, indicate citizenship status:

T-shirt size: Other size:

Are you interested in applying for Camp Sunrise 2017? Have you attended a camp before?

Yes No If yes, what type of camp and in what capacity?

What position are you applying for: Camp Counselor Staff Program/Activities Staff

If camp counselor which age group do you prefer?

Please check the activities you would be comfortable leading.

Campfire programs Ropes Course Team Sports Photography

Music/Singing Story Telling Arts & Crafts Archery

Nature Other

Do you speak a language other than English? Yes No Specify:

Have you ever been convicted of a crime? Yes No If yes, attach an explanation.

Are you certified in CPR? Are you Certified in First Aid?

Professional License No. State:

Please attach a copy of your professional license (All information will be held confidential, unless specified otherwise).

Please attach a copy of your driver’s license

Name:

SunSibs Volunteer Application: Page 2 of 5

Employment & Volunteer History Present employer: Employer’s name:

Your position:

Address: Phone:

Supervisor’s name: Employed since:

Volunteer Experience (Most recent): Position: Agency: Date(s):

Position: Agency: Date(s):

Education & Youth Experience Highest grade completed: Special Training:

What experience have you had working with children?

Please identify what level of experience you have had working with children who have special

educational or behavioral concerns: No Experience Some Experience

A lot of Experience

Please describe:

What special gifts or talents would you like to bring to camp?

References: List two people other than relatives who would be willing to serve as a personal reference.

Name: Telephone number: E-mail:

Street Address: City: State/Zip:

Name Telephone number: E-mail:

Street Address: City: State/Zip

Name:

SunSibs Volunteer Application: Page 3 of 5

Agreement to take part in SunSibs Overnight activities: I want to take part in all SunSibs activities and, in consideration of the benefits to be derived I expressly waive all claims against Johns Hopkins University, Johns Hopkins Health System Corporation and any of their affiliates and, SunSibs staff or their representatives on account of any accident, injury and or illness that may occur during the camp period.

Signature of Volunteer: Date:

Consent for Medical Treatment and Emergency Medical Treatment: I hereby authorize the Medical Director of SunSibs or such designee(s) as the Medical Director may appoint, to provide for the giving of medical treatment and emergency medical care or treatment, including but not limited to medicines, immunizations, x-rays, tests, dental and minor surgical treatment, hospitalization, general anesthesia or other medical treatment as may be appropriate while in the care of SunSibs. Notification of the emergency contact will always be attempted prior to providing emergency medical treatment. I understand that information pertaining to me may be shared with/released to appropriate personnel for the purpose of treatment (including, but not limited to camp medical staff and/or insurance companies). I agree to be financially responsible for the cost of all emergency medical care and treatment provided.

Signature of Volunteer: Date:

Photo Release Permission: I give permission for any photographs and/or videos that may be taken during the camp period and include my likeness to be used in connection with video slide presentations, future program publicity, fund raising, educational activities, or teaching purposes. I also give permission for these to be shared with program participants (campers & staff). I waive any claims to compensation and rights regarding such use.

YES NO Signature of Volunteer:

Permission to complete attitude surveys and program evaluation surveys: I agree to anonymously fill out attitude and program evaluation surveys during SunSibs programming. Information from surveys will be used to evaluate the program and for educational or teaching purposes.

YES NO Signature of Volunteer:

Applicant’s Certification and Agreement I certify that all information is true and has been given voluntarily. I understand that this information may be disclosed to any party with legal and proper interest. I release the agency from any liability whatsoever for supplying such information.

Signature: Date:

Agreement of Confidentiality My signature on this form indicates my understanding that any patient names or information I may receive while participating as a volunteer at SunSibs is confidential information and will be treated as such by me. Signature: Date:

Permission to include contact information in SunSibs Alumni & Staff Directory I give my permission to include contact information about me in the SunSibs Alumni & Staff directory which will be distributed to program participants.

YES NO Signature:

Name:

SunSibs Volunteer Application: Page 4 of 5

Persons to be contacted in case of an emergency: Name: Home Phone: Other Phone: Name: Home Phone: Other Phone:

Insurance Information If Medicaid, specify number: Name of Insurance Company: Address: Phone Number: Policy Number or CIN: If Group Insurance, specify company of employment: Name of Policy Holder: Social Security # of Policy Holder:

Please include a copy of your insurance card.

In order to volunteer for SunSibs you will need to meet all Johns Hopkins Medical Institution standards regarding health status, vaccinations and immunizations. Please provide the paperwork below to receive clearance from the Johns Hopkins Department of Occupational Health PRIOR to working at SunSibs.

1. You must be screened for tuberculosis and must be determined to be free of active infectionwithin 6 weeks of the start of camp. For 2017, that date is April 14th. Any volunteer with apositive reaction to the PPD test is advised to follow-up with a chest x-ray and further medicaltreatment if so determined.

2. A copy of your immunization records. All volunteers must provide documentation of thevaricella and measles/mumps/rubella (MMR) vaccinations.

Name:

SunSibs Volunteer Application: Page 5 of 5

General Health History

LAST EAR INFECTION (Date) YES NO

MUMPS MEASLES GERMAN MEASLES

YES NO YES NO YES NO

HEART PROBLEMS SEIZURES

DIABETES

YES NOYES NO

YES NO ASTHMA IMMUNIZATION HISTORY: (All immunizations must be kept up to date.) DPT SERIES BOOSTER POLIO BOOSTER

LAST TETANUS BOOSTER LAST TUBERCULIN TEST OTHER

MMR (MEASLES, MUMPS, RUBELLA) ANY RECENT/CURRENT INFECTIOUS/COMMUNICABLE DISEASE EXPOSURE?

(PLEASE EXPLAIN): ALLERGIES TO: HAY FEVER YES NO

INSECT STINGS IVY POISONING MEDICATIONS

YES NO YES NO YES NO

OTHER ______________________________________________________________________ RECOMMENDATIONS/RESTRICTIONS:

DIET: _____________________________________________________________________

SWIMMING/DIVING: ________________________________________________________ ACTIVITY LEVEL: OTHER: __________________________________________________________________

MEDICATIONS: MEDICATIONS MUST BE BROUGHT IN ORIGINAL PHARMACY CONTAINERS

DRUG DOSE TIME DAYS OF WEEK

13157644v.2 Rev. 08/2011 1

11019 McCormick Road, Suite 120, Hunt Valley, MD 21031 800-635-1649 www.PinkertonScreening.com

DISCLOSURE AND AUTHORIZATION [IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION]

DISCLOSURE REGARDING BACKGROUND INVESTIGATION

The Johns Hopkins Hospital Department of Volunteer Services (“The Company”) may obtain information about you for employment purposes from a third party consumer reporting agency. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews with sources such as your neighbors, friends, or associates. These reports may contain information regarding your credit history, criminal history, social security verification, motor vehicle records (“driving records”), verification of your education or employment history, or other background checks. Credit history will only be requested where such information is substantially related to the duties and responsibilities of the position for which you are applying. You have the right, upon written request made within a reasonable time, to request whether a consumer report has been run about you and disclosure of the nature and scope of any investigative consumer report and to request a copy of your report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted by Pinkerton Consulting and Investigations, 11019 McCormick Road, Suite 120, Hunt Valley, MD, 800-635-1649, or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing the Company to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.

New York and Maine applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by The Johns Hopkins Hospital Department of Volunteer Services by contacting the consumer reporting agency identified above directly. You may also contact the Company to request the name, address and telephone number of the nearest unit of the consumer reporting agency designated to handle inquiries, which the Company shall provide within 5 days.

New York applicants or employees only: Upon request, you will be informed whether or not a consumer report was requested by The Johns Hopkins Hospital Department of Volunteer Services, and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. By signing below, you also acknowledge receipt of Article 23-A of the New York Correction Law. Oregon applicants or employees only: Information describing your rights under federal and Oregon law regarding consumer identity theft protection, the storage and disposal of your credit information, and remedies available should you suspect or find that the Company has not maintained secured records is available to you upon request. Washington State applicants or employees only: You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

ACKNOWLEDGMENT AND AUTHORIZATION

I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by the Company at any time after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Pinkerton Consulting and Investigations, 11019 McCormick Road, Suite 120, Hunt Valley, MD, 800-635-1649, another outside organization acting on behalf of the Company, and/or the Company itself. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

New York applicants or employees only: By signing below, you also acknowledge receipt of Article 23-A of the New York Correction Law.

Minnesota and Oklahoma applicants or employees only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company. □

California applicants or employees only: By signing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report at no charge if one is obtained by the Company whenever you have a right to receive such a copy under California law. □

Print Name:

Signature: Date:

13157644v.2 Rev. 08/2011 1

11019 McCormick Road, Suite 120, Hunt Valley, MD 21031 800-635-1649 www.PinkertonScreening.com

Background Information Form

PLEASE PRINT CLEARLY

Last Name First Name Middle Name

Maiden/Alias Names

Date of Birth Social Security Number

Address City/State/Zip

Addresses for the Previous 10 Years

Street Address City/County State Zip Code Dates of Residency From – To

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NAME OF MOST RECENT EMPLOYER EMPLOYER PHONE

EMPLOYER ADDRESS

SIGNATURE DATE