Camp Counselor Application
must be fully completed
and submitted prior to the due date before consideration.
Applicants under the age of 18 must complete a Junior Counselor application, and their parent or guardian must request that they be assigned as a counselor.
Summer Camp (7/20-7/24)
Summer Camp (7/24-7/28)
Native Hawaiian and Other Pacific Islander
Hispanic or Latino (of any race)
American Indian and Alaska Native
Black or African American
Date of Birth:
Do you require a Community Service letter?
Preferred Method of Communication?
Relationship to Counselor:
Health Insurance Information:
Coverage for illnesses or injury while participating in programs at Camp Dream is the responsibility of the parent or guardian of the participating Counselor. Please provide medical/hospital insurance coverage information below.
Policy or Group Number:
We are entrusted to provide a safe and healthy environment for all of our campers. To aid us in accomplishing this goal, we ask that each applicant inform us if they have any medical conditions.
SPECIAL NOTE: Inform the Camp director immediately if you are exposed to any communicable disease (chicken pox, mumps, measles, flu etc) within one month of the camping session.
List All Limitations:
List All Limitations:
List All Allergies
The nurses will dispense all medications. All medications brought onto the premises must be checked in to the nurse and kept locked in the medical cabinet for the safety of the campers. Please list all prescription AND over the counter medications that you take.
Are you taking any medication?
List All Medications:
Are you CPR Certified?
Have you taken a first aid course?
Are you lifeguard certified?
Other relevant certifications and skills (e.g. physical therapist, speech therapist, sign language etc.):
Have you ever been charged with or convicted of sexual abuse, assault, battery, neglect or molestation?
If yes, a detailed explanation must be provided.
How did you hear about Camp Dream?
Friend of Camp
Social Media (Facebook, Twitter, etc.)
Have you ever been a camp counselor before?
Please give the names, email address and phone numbers of three persons not related to you, that you have
known at least one year we can contact for references.
Reference 1 Name
Reference 1 Email
Reference 1 Phone
Reference 2 Name
Reference 2 Email
Reference 2 Phone
Reference 3 Name
Reference 3 Email
Reference 3 Phone
Affirmation and Consent
I hereby affirm that all information given is true and complete. By signing below, I warrant that all information entered within this application is complete and accurate. I understand and agree that if I have misled Camp Dream Foundation, my application and/or staff position will be terminated immediately.
I am assuming the responsibility as counselor for campers assigned to me for the duration of the camping session. I release, absolve, indemnify, and hold harmless Camp Dream Foundation and its affiliates. In case of injury to myself, I hereby waive all claims against Camp Dream Foundation and its affiliates. I also acknowledge that all information provided in this application is to be kept confidential.
I release and waive any potential future claims against Camp Dream Foundation and its affiliates, employees, staff, and volunteers for any property damage and/or personal injury arising out of any activity connected with this camping session and/or use of camping facilities, including by way of example only and without limitation, transportation to and from events, use of facilities and equipment, and negligence of any person or entity.
Consent to Perform Criminal Background Checks
I agree that by submitting this application, I am granting the Camp Dream Foundation permission to perform background checks to ensure the safety of the campers. Background checks may include, but are not limited to criminal background checks, driver’s license validation and sex offender listings.
Photographs, Likenesses, Images and Recordings
I give my consent to Camp Dream Foundation, Inc. to photograph and/or make video or audio recordings of me without limitation and to use such photographs, videotapes or audiotapes and my name, likeness and voice and/or any related stories (“Likeness”) in connections with any of the work, programs, projects, fundraising or other endeavors of Camp Dream in any and all media, including without limitation, electronic or digital media, whether known or unknown at this time, forever worldwide and without restriction, without consideration or compensation of any kind. I release, discharge and hold harmless Camp Dream Foundation, Inc. and its affiliates, including, without limitation, its officers, directors, shareholders, employees, agents and contractors (“Camp Dream”) from any and all claims and demands arising out of or in connection with the use of my Likeness, Including slander, libel, invasion of privacy or publicity, and/or copyright infringement . This Release applies to me and my heirs, legal representatives and assigns and I do release, discharge and hold harmless Camp Dream Foundation, Inc. from any claim or demand whatsoever arising out of or in connection with such use.
Diminished Capacity Waiver
Hereinafter "Camp Dream" will pertain to the camp as a whole, and any instruments thereof including, but not limited to, other volunteers, staff members, and administration personnel. Camp Dream is a summer camp designed and intended to accommodate campers with a diverse array of mental and physical disabilities. Due to their diminished capacity some campers are not aware when they are acting inappropriately and/ or incapable of adhering to social norms indicative of a civilized society. This type of behavior has the potential to be offensive to staff members, volunteers, or any others who are not well versed with the propensities of those who are mentally impaired. While Camp Dream tries to minimize these types of incidents, it is impossible to eliminate them completely. Nonetheless, it is the responsibility of anyone who witnesses such behavior to report it to an official of Camp Dream immediately so that it can be addressed properly as in no way does Camp Dream condone such behavior nor will Camp Dream allow the perpetuation thereof. In acknowledgement thereof, I understand the aforementioned risk, and in consideration for being allowed to volunteer at Camp Dream I hereby voluntarily consent to exposure to the aforementioned environment hereby assuming all risks of pertinent thereto and waiving Camp Dream from all liability arising therefrom. This waiver shall be construed to be contained in full as delineated hereunto and may not be modified by oral agreement.
By signing and dating below, I give consent and acknowledge all of the above stated policies.