HomeMy WebLinkAboutBSA Applications & CORI Forms r
Cape Cod & Islands Council Boy Scouts of America
Greenough Scout Reservation
Yarmouth Port, Massachusetts APPLICATION FOR POSITION
Please read CAREFLTLLY before proceeding and then fill out completely,including
�. ' � � the names,complete addresses and phone numbers of references.Applicants are not
' required to give any information on tlus form that is prohibited by Federal, State or
� � Local Law.
Applicants are considered for all positions without regard to Race, Color,Religion,
Gender,National Origin or the presence of a health problem or handicap that is
nnrelated to the person's ability to perform the job assigned.
Applicants accepted for employment are hired on a temporary basis and employment
is based upon the continued satisfaction and needs of the facility, and may be
� � terminated on written notice by the Director.Any decision in this regard will be fmal.
PLEASE PRINT CLEARLY
Last Naaie: _ __ ___ ____ _- --�irst-(Ft�1�)I?3eu3et ___ _ __
Social Security#: — — Home Telephone:( )
Home Address: City: State: Zip: '
E-mail Address:
Mailing Address(if different): City: State: Zip:
Age as of JULY lst: Date of Birth:M D Y Telephone:( , )
If you are a student-School:
Major subjects of study:
If you are now or have been employed-when,where,occupation:
Have you ever been convicted of a felony?(You may answer"NO"if your conviction has been ordered sealed,expunged or eradicated.)
Yes No.Conviction of a crime is not an automad¢bar to employment-all circumstances will be considered,including what you
were convicted of and how long ago.Please provide complete information about the conviction by attaching a sepazate statement.Are you
permitted to become lawfully employed in this country7 Yes No.(Proof of citizenship or immigration status will be required upon
employment.)
Do you have any physical disabilities,which might interfere with performance of the job,for which you aze applying7 Yes No.
If so,please explain:
FOR OFFICE USE ONLY
Camp Position: Salary:$
Employment: Starting Date: Finishing Date:
Date Contract Sent: Date Contract Returned:
References: l. 2. 3.
Working Papers Received: Medical Form Received: Y N
Driver's License: Employment Documents Received:I-9 W-4
Certi�cations:CPR: FR: SLG: NCS: NRA: BLS: EMT: WSL•
Rev. 12/9/2010
I
Cape Cod & Islands Council Boy Scouts of America -
4
PREVIOUS CAMPER EXPERIENCE �
�
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When: Where: Type of Camp: �
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}
T e of Cam �
When: Where: YP P� ;
T e of Cam j
When: Where: YP P�
PREVIOUS CAMP STAFF EXPERIENCE
When: Where: Type of Camp: Position held:
i
When: VJhere: Type of Camp: Position held: �
When: Where: Type of Camp: Position held: "
List preferences for program and position(Cub day camp;North Star; Maritime,Ultimate Greenough) j
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1. First choice ( C N M UG ) �
2. Second choice ( C N M UG )� �
3. Third choice ( C N M UG ) ;
s
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CURRENT CERTIFICATIONS �
(Please check those that apply)
NRA Instructor: /Expiration Date: NCS: /Expuation Date:
American Red Cross Water 5afety Instructor:_/Expiration Date:
Scout Lifeguard:_/Expiration Date: �
ARC Senior or Advance Lifesa�ing or Equal:_/Expiration Date: CPR:_/Expirarion Date: �
EMT:_/Expiration Date: CAR/BLS:_/Expiration Date: �
{
Standard First Aid: /Expiration Date: Other:
€
;
List three personal references who are not relatives. �
_ _ _ �
Name: Telephone Number:(____� �
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Name: Telephone Number:(_�
Name: Telephone Number:(_�
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I authorize investigation of all statements contained in this application for employment as may be i
necessary in arriving at an employment decision. I authorize my previous employers, schools and other
references to furnish the information requested. I hereby declare that the information provided by me '
in this application for employment is accurate and complete to the best of my knowledge. I understand �i
that any falsification or misrepresentation in the application is cause for discharge. ,
II;� APPLICANT'S SIGNATiJRE: DATE:
DATE:
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SIGNATURE OF PARENT/GUARDIAN IF APPLICANT IS UNDER 18 YEARS OF AGE
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� Please mail completed application to: Cape Cod&Islands Council, 247 Willow St.,Yarmouth Port, MA 02675
;
I
i Rev. 12/9/2010
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Ca e Cod and Islands Council, Inc. #224 ^(��1
p Scouts of America � ''� �
Boy �► �,
�,�5� � 33.a, Serving Cape Cod,Martha's Vineyard,and Nantucket Islands
�7
Agency Code:CGCCI
172H
FE172
Chapter 6,Sec.172H CORI REQUEST FORM
Cape Cod&Islands Council,Inc.,Boy Scouts of America,is requesting a11 the available criminal offender record information(CORI)
on the following individual from the Criminal History Systems Board pursuant to Chapter 6,Sec. 172H which mandates organizations
primarily engaged in providing activities or programs to children 18 years of age or less that accepts volunteers,to obtain all CORI
regarding staff and volunteers. A copy of the Cape Cod&Islands Council CORI policy is available on our website or may be obtained
by contacting the Council Service Center at 508-362-4322.
Applicant Information(Please Print)
Last Name First Name Middle Name
Maiden Name or Alias(If applicable) Place of Birth
Date of Birth Social Security Number ID Theft Index PIN* Mother's Maiden Name
(Requested,not required)
Current and Former Addresses
Sex: Height: ft. in. Weight: Eye Color:
State Driver's License Number:
This information was verified by reviewing the following form of governxnent issued photographic identification:(Driver's
License,Passport,etc.)
Signature of Unit Committee Chairman
I understand that any person who willfully requests,obtains or seeks to obtain criminal offender record information(CORn under false pretenses,or
who willfuily communicates or seeks to communicate CORI to any agency or person except in accordance with the provisions of M.G.L.c.6,§§168
through 178B,inclusive,shall for each oft'ense be fined not to exceed five thousand dollars($5,000.00),or imprisoned in a jail or house of correction
for up to one year,or both and/or may be ordered by the Criminal History Systems Board to pay civil fines not to exceed five hundred($500.00)for
each willful violation.
*The CHSB Identify Theft Index PIN Number is to be completed by those applicants that have been issued an Identity Theft Index PIN Number by the
CHSB. Certified agencies are required to provide all applicants the opporluniTy to include this information to ensure the accuracy of the CORI request
pmcess.
Please attach a copy of the applicant's photo ID to this form.
Rev 10/25/2010
Tel. (508)362-4322 247Willow Street
Fax(508) 362-4323 www.scoutscapecod.org Yat'tnouth Po�^t,MA 02675
� Annual BSA Health and Medical Record High-adventure base participants:
, Part A Expedition/crew No.:
GENERAL INFORMATION or staff position:
Name Date of birth Age Male❑ Female❑
Address Grade completed(youth only) ' .
City State Zip Phone No.
Unit leader Council nameMo. Unit No.
Social Security No.(optional;may be required by medical facilities for treatment) Religious preference
Health/accident insurance company Policy No.
O
Z ATTACH A PHOTOCOPY OF BOTH SIDES OF INSURANCE CARD.IF FAMILY HAS NO MEDICAL INSURANCE,STATE"NONE."
V In case of emergency,notify:
,��.. Name Relationship
� Address
O
v Home phone Business phone Cell phone
VAlternate contact Alternate's phone
� HEALTH HISTORY .
� Are you now,or have you ever been treated for any of the following: Allergies or Reaction to:
� Yes No Condition Expiain Medication
W Asthma Last attack: Food,Plants,or Insect Bites
Diabetes Last HbAic: �
Hypertension(high hlood pressure) Immunizations:
Heart disease(e.g.,CHF,CAD,MI) The following are recommended by the BSA.
StrokelTlA Tetanus immunization is required and must
Lung/respiratory disease have been received within the last 10 years.If
Ear/sinus roblems had disease,put"D' and the year.If immunized,
p check the box and the year received.
Muscular/skeletal condition Yes No Date
Menstrual problems(women only) ❑ p Tetanus
y Psychiatric/psychological and ❑ ❑ pertussis
d emotional difficuities
�� Behavioral disorders(e.g.,ADD, ❑ ❑ Diphtheria
� ADHD,As er er syndrome,autism) ❑ ❑ Measles
— Bleedln disorders ❑ ❑ Mumps
a Faintin s ells ❑ ❑ Rubella
Th roid disease ❑ ❑ Polio
Kidne disease ❑ ❑ Chicken pox
Sickle cell disease ❑ ❑ Hepatitis A
Seizures Last seizure: ❑ ❑ Hepatitis B
Slee disorders e. .,slee a nea Use CPAP:Yes❑ No❑ p ❑ influenza
AbdominaVdi estive roblems
Sur e ❑ ❑ Other(i.e.,HIB)
Serious in'u ❑Exemption to immunizations claimed
m Other (form required).
� MEDICATIONS (For more informatlon about immunizations,
List all medications currently used.(if additional space is needed,please photocopy as weli as the immunization exemption form,
this part of the health form.)Inhalers and EpiPen information must be inciuded,even see Scouting Safery on Scouting.org.)
if they are for occasional or emergency use only.
Medication Medication Medication
Strength Frequency Strength Frequency Strength Frequency
Approximate date started Approximate date started Approximate date started
Reason for medication Reason for medication Reason for medication
Medication Medication Medication '
Strength Frequency Strength Frequency Strength Frequency
Approximate date started Approximate date started Approximate date started
Reason for medication Reason for medication Reason for medication
N
� Administration of the above medications is approved by(if required by your state): /
ParenVguardfan slgnatiae and/or MD/DO,NP,a PA signattae
� Be sure to bring medications in sufficient quantities and the original containers.Make sure that they are NOT
u- e�ired,including inhalers and EpiPens.You SHOULD NOT STOP taking any maintenance medication.
680-001
2011 Printing
Rev.2/2011
High-adventure base participants:
P�B Expedition/crew No.:
INFORMED CONSENT AND HOLD HARMLESS/RELEASE AGREEMENT or staff position:
I understand that participation in Scouting activities involves a certain degree of risk and can be physically,mentally,and ernotionally
demanding. I also understand that participation in these activities is entirely voluntary and requires participants to abide by applicable
rules and standards of conduct.
In case of an emergency involving me or my child, I understand that every effort will be made to contact the individual listed as the
emergency contact person.In the event that this person cannot be reached,permission is hereby given to the medical provider
selected by the adult leader in charge to secure proper treatment,inciuding hospitalization,anesthesia,surgery,or injections of
medication for me or my child. Medical providers are authorized to dlsclose protected health information to the adult in charge,camp
medical staff,camp management,and/or any physician or health care provider involved in providing medical care to the participant.
Protected Health Information/Confidentiai Health Information(PHI/CHI)under the Standards for Privacy of Individually Identifiable
Health Information,45 C.F.R.§§160.103, 164.501,etc.seq.,as amended from time to time,inciudes examination findings,test results,
and treatment provided for purposes of inedical evaluation of the participant,follow-up and communication with the participant's
parents or guardian,and/or determination of the participant's ability to continue in the program activities.
I have carefully considered the risk involved and give consent for myself and/or my child to participate in these activities. I approve
the sharing of the information on this form with BSA volunteers and professlonals who need to know of inedicai situations that might
require special consideration for the safe conducting of Scouting activities.
I release the Boy Scouts of America,the local councii,the activity coordinators,and all employees,volunteers,related parties,or other
organizations associated with the activity from any and all claims or liability arising out of this participation.
❑ Without restrictions.
❑ With specfai considerations or restrictions(list)
TALENi RELEASE AGREEMENT
I hereby assign and grant to the local council and the Boy Scouts of America the right and permission to use and publish the photographs/
film/videotapes/electronic representations and/or sound recordings made of ine or my child at all Scouting activities,and I hereby .
release the Boy Scouts of America,the local council,the activity coordinators,and all employees,volunteers,related parties,or other
organizations associated with the activity from any and all liability from such use and publication.
I hereby authorize the reproduction,sale,copyright,exhibit,broadcast,electronic storage,and/or distribution of said photographs/
film/videotapes/electronic representations and/or sound recordings without limitation at the discretion of the Boy Scouts of America,
and I specifically waive any right to any compensation I may have for any of the foregoing.
❑Yes ❑No
ADULTS AUTHORIZED i0 TAKE YOUiH TO AND FROM EYENTS:
You must designate at least one adult.Please include a telephone number.
1.Name Telephone
2.Name � Telephone
3.Name Telephone
Adults NOT authorized to take youth to and from events:
1.Name
2.Name
3. Name
I understand that,if any information 1/we have provided is found to be inaccurate,it may limit and/or eliminate the opportunity
for participation in any event or activity.
If I am participating at Philmont,PhilmontTraining Center,Northern Tier,or Florida Sea Base:I have also read and
understand the rlsk advisories explained in Part D,including height and weight requirements and resfrictions, and understand
that the participant will not be allowed to participate in applicable high-adventure peograms if those requirements are not met.
The participant has permission to engage in all high-adventure activities described,except as specifically noted by me or the
health-care provider.
Participant's name
Participant's signature Date
Parent/guardian's signature Date
, Qf partfcipaM fs under the age of 18)
Second parenUguardian signature Date
(f required;for example,C/�
This Annual Health and Medical Record is valid for 12 calendar months.
Part B Full name: ppg; sao-oo,
2011 Printing
Rev.2/2011