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Extremely Important Staff Information Sheet 2008
**It is extremely important that you complete this form accurately and in its entirety. We MUST have this form on record for ALL employees of Camp Echo Lake. There are 5 parts to this form, please complete all 5 parts.
Name: Email Address:
Date of Birth:
Current Phone Number: Social Security Number:
Current Address:
Emergency Contact Name: Emergency Contact Phone Number:
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IN ORDER TO WORK AT CAMP ECHO LAKE, EVERY STAFF PERSON MUST HAVE HIS OR HER OWN INSURANCE COVERAGE. If you do not have health insurance of some kind, you can not work at Echo Lake. If you have insurance on your own, through your parents, through work, through school, or through BUNAC / CCUSA / Camp Leaders that is fine and most likely provides extensive coverage. Any general medical insurance (which is the most frequent insurance needed for such things as prescriptions, x-rays, crutches, etc...) that will cover all your medical or insurance needs is fine with us. Echo Lake does not provide medical or insurance coverage for staff. Please complete the below information & attach a copy of BOTH SIDES of your insurance card to the Insurance Card Form.
I am covered by the following Insurance Company and/or policy:
* Name of Insurance Company or Policy:
* Name of Person Insured:
* Policy Number:
*Part 3: Automobile at Camp/Driver’s License Information
We are requesting this information so that you may be properly insured at any time you may transport fellow counselors or campers in the conduct of camp business. (Please complete both A & B below…)
A) This form should be completed by the following Staff Members who are either:
1. Planning to bring automobiles to camp (You MUST be over 18 years of age as of 6/1/08)
2. 21 years of age or older with a valid driver’s license (21 years of age or older as of 6/28/08.)
Age as of June 28, 2008: Birth date
Driver’s License Number:
Expiration Date: State of Issuance:
B) If you are planning to bring a car to camp (You MUST be over 18 years of age as of 6/1/08):
Make, Model, and Year of Vehicle:
Registration Number:
License Plate Number: State of Issuance:
*Part 4: Special Time Off Request
Any staff person requiring special time off for a family function, job interview, wedding or similar obligation should fill out this form. Please indicate the situation, date and time needed off and any other important information pertaining to that time off. (Please leave this blank if this does not apply to you.) Your request will then have to be approved by the camp directors and head counselors. Be aware that special time off may require an adjustment to your regular weekly time off schedule.
Date(s) Needed for Special Time off:
Reason for Special Time off:
*Part 5: Certifications
If you have any official certifications or training pertaining to camp (i.e. CPR, first aid, life-guarding, WSI, WFR, EMT, coaching levels, etc…), please list below:
Type of Certification:
Certification Issued by (i.e. American Red Cross):
Date Certification was Received: Date Certification Expires:
*Please email or mail a photo-copy of certification certificate or certification card!!
*Please email or mail a photo-copy of certification certificate or certification card to camp!!!
*Please "sign" this form by putting your initials here:
