Good Samaritan Medical CenterPresents
YMCA of the Rockies
Estes Park, CO
August 18-20, 2017
You are completing this form to be a volunteer of Retreat & Refresh Stroke Camp. Please complete all requested information in each section. Volunteers are required to be at least 18 years of age and be in good health. Anyone younger than 18 will need to request a youth volunteer application for consideration. It is your responsibility to let us know if special accommodations need to be arranged. Healthcare background or training welcomed, but not necessary.
All volunteers are asked to arrive at camp by
Friday and to stay for the duration of the retreat. Camp ends Sunday afternoon around 2 pm. Preference will be given to volunteers who are able to stay for the entire weekend.
Please complete this form in its entirety. To finish, click the submit button at the bottom of the form. After submitting, you will receive a confirmation message, as well as a confirmation email. Please contact us at 309-688-5450 if you do not receive confirmation of your submission.
* Required Fields
Name Badge Should Read:
Degree (if applicable)
Your name, address, phone number, and email address will be distributed to all in attendance at camp.
*Do you require a special diet beyond heart healthy, diabetic friendly or have any food allergies?
If yes, please describe:
Our best efforts will be made to accomodate your request.
While our best efforts will be made to accommodate your request, we suggest you bring snacks/food to supplement your diet if you are concerned about having food available that you can eat.
*In case of emergency, contact:
*How did you hear about camp?
Experience working with the stroke population: (prior experience not required)
Camp Experience: (Brief History if applicable)
Volunteers are not expected to assist survivors and caregivers with activities of daily living (bathing, dressing, grooming, etc.) The following activities are ones you may be asked to assist with while at camp. Volunteer assignments are made at camp, and all volunteers are asked to assist wherever they see a need. (Activities vary based on retreat center location, time of year, and accommodations.)
Assisting survivors w/buffet line
decorating for theme
Please list any current certifications or credentials you have which would be helpful
in the camp setting (example: CPR, First Aid, etc.):
Please list any other information about yourself that you wish to share:
Stroke Camp Volunteer
Thank you for agreeing to volunteer for this important weekend in the life of stroke survivors
and caregivers in your area.
Your commitment for the retreat weekend would begin by 10:00am Friday morning and end Sunday around 2:00 pm.
For the comfort of our survivors and the continuity
of the camp, it is important to make every effort to attend for the entire retreat.
Stroke survivors and caregivers arrive between
2:30 and 4:00 on
and depart at the close of
the event Sunday. We ask that volunteers plan to attend the entire retreat unless other
arrangements have been made. You will receive a schedule, directions to camp and
what to bring approximately two weeks before camp.
indicate your availability for the camp date for
YMCA of the Rockies
Estes Park, CO, August 18-20, 2017
*I will be there for the entire retreat(Preferred)
Or: available beginning
Depending on the facility, volunteers typically share a sleeping room with one or more volunteers of the same gender. If you have a friend, colleague, or spouse volunteering for this camp that you would like to room with, please list their name/s here. We will do our best to accommodate rooming requests.
There are opportunities for educational/experiential sessions throughout the retreat weekend. If you have a topic of interest and would like to present, please list it here and we will be in touch.
To submit this application please read the policies and procedures below, sign , date, and click submit.
member of the Retreat & Refresh Stroke Camp (hereafter “Camp”)
staff: counselors, activity staff, medical staff, and administrative staff has
a responsibility to provide for and protect the health and well being of
campers (stroke survivors and their caregivers).
read the following Practices and Policies Agreement carefully and
thoughtfully then sign the statement of compliance that follows.
Medical Services: The camp nurse must be advised promptly of any
injuries or health problems. All volunteers must follow decisions made by
camp nurse for themselves and campers.
Telephone Calls: Volunteers will not be paged for calls, except in
case of emergency. The facility phone cannot be used for personal calls. Cell
phones can be used during free time, but are to be kept silent during camp
group activities. Often cell coverage is spotty at our camps.
Valuables and Cash: Everyone is urged not to bring highly valued
clothing and accessories. The Camp cannot be responsible for loss or damage to
Professionalism: Confidential information given and received
before, during, or after a camp must be held in confidence. Volunteers must
act professionally toward all campers.
Smoking on the camp grounds is forbidden and is extremely dangerous. If
smoking is permitted, there will be a designated area to be used during your
Alcohol and Drugs: The use of alcoholic beverages or illegal drugs
while caring for stroke survivors and their caregivers is strictly forbidden
and will be considered grounds for sending a volunteer home. To be under the
influence of alcohol or drugs in camp is not consistent with a volunteer’s
responsibility to the campers. Camp Nurse or the Camp Director can release
anyone who is under the influence during the weekend.
Camp Site Requirements: All volunteers and campers must
abide by the contractual agreement signed by Retreat & Refresh Stroke Camp™. Camp may have
a strict non-alcohol and smoking policy. No animals, firearms, ammunition, weapons, power tools, explosives or
poisonous substances allowed on the property. The Emergency and Fire Policy
will be available on site for reference as needed.
Safety at Camp: In order to protect both campers and volunteers, strict
safety policies will be followed which include the Golf Cart and Walkie Talkie
policies listed below.
Golf carts are for the purpose of transporting stroke survivors and caregivers
between points at camp or moving equipment when necessary. The Camp Director
will appoint golf cart drivers for the camp. Any use other than what is listed
above must be approved by the camp director. Anyone under the age of 18 or who
doesn’t have a valid driver’s license is exempt from driving golf carts.
Walkie Talkie use: Often camp locations have poor or spotty cell
phone coverage. Because of that fact, if there is an opportunity for campers
to explore the outdoors and be away from the camp site, they must be
accompanied by volunteers who have a walkie talkie. The base will be left with
someone at the main site and agreed upon through the camp director before
that I am volunteering to perform services for camp, with no expectation of pay
or remuneration of any kind. I understand that I will not be employed by or be
an employee of camp. Because I will not be an employee, I understand that I
will not be covered by either state unemployment or state workers’ compensation
laws or any camp insurance policy.
acknowledge that my volunteer services will not entitle me to any employee
benefits provided by camp to its employees. Either I or camp may decide to
terminate my volunteer services at any time and for any reason, with or without
have read the above Practices and Policies and agree to abide by the
regulations established or the retreat. I am fully aware that adhering to the
rules will by my sole responsibility. Deviation from these rules may be cause
for immediate dismissal from the Camp.
of Volunteer *Date
By typing name I agree to the above policies and procedures