Upstate NY Area Camp

August 2-4, 2024

Beaver Camp | Lowville, NY

Secure Online Event Registration

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 is welcomed, but not necessary.

All volunteers are asked to arrive at Jeb's in Lowville by 2:30 PM on Friday and asked to stay for the duration of the weekend. Camp ends Sunday afternoon around 2:00 PM.

Theme: Magical Memories Celebrating 20 Years of Stroke Camp

Bringing back some of the best and brightest moments experienced over the past 20 years at Stroke Camp. Some Jeopardy, a talent show, classic skits, and more await...

BASIC INFORMATION

You are a

Volunteer

Name

Name Badge Should Read (don't include last name)

Phone Number

Address

Date of Birth

Age should be between 18 and 89 as of April 5th, 2024

Gender

Male
Female
Other/Prefer not to say

Occupation

Employer

T-Shirt Size

EMERGENCY CONTACT INFORMATION

Name

Phone Number

Relation

ADDITIONAL HELPFUL INFORMATION

Do you have any food allergies or require a special diet?

Our best efforts will be made to accommodate your request, however if you are concerned about having food available that you can eat, we suggest bringing snacks and/or food to supplement your diet.

How did you hear about Stroke Camp?

Do you have experience working with the stroke population?

Do you have any camp experience (General or Stroke Camp?)

Please name any CURRENT certifications or credentials you have which would be helpful in the camp setting

None
First Aid
CPR
Other

Please list any other information about yourself that you wish to share

STROKE CAMP VOLUNTEER EXPECTATIONS

ARRIVAL

Your commitment for the retreat weekend would begin by 9:30 am Friday morning and end Sunday around 2:00 PM. For the comfort of our survivors and the continuity of the weekend, it is IMPORTANT to make every effort to attend the entire retreat.

Stroke Survivors and caregivers arrive between 1:30 PM and 3:30 PM on Friday and depart at the close of the event Sunday. We ask that volunteers plan to attend the entire weekend retreat unless other arrangements have been made.

Will you be present the entire weekend?

ACTIVITIES

Volunteers are NOT expected to assist survivors and caregivers with activities of daily living (bathing, dressing, grooming, etc...) The following activities are some you MAY be asked to assist with while at camp. Volunteer assignments are made AT camp, and all volunteers are asked to assist where ever they see a need. (Activities vary based on retreat center, location, time of year, and accommodations.)

Crafts
Massage
Rock Climbing
Discussion Groups
Sports
Manicures
Education Sessions
Paraffin Dip
Fishing
Assisting survivors through buffet line
Snack preparation
Decorating for theme
Swimming
Boating
Registration/Admin.

ROOM ASSIGNMENTS

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. While there are NO guarantees, we will do our best to accommodate rooms requests.

Rooming Request

INTERESTS AND CONFIRMATION

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.

List any interests/thoughts

Approximately one or two weeks before camp, VIA EMAIL, you will receive:

Weekend Schedule
Directions to Camp
Packing Check Guide
Address List
List of Roles and Expectations

AGREEMENT

AUTHORIZATION FOR USE AND/OR DISCLOSURE OF INFORMATION AND GENERAL RELEASE

United Stroke Alliance®, a tax-exempt organization, also known as Retreat & Refresh Stroke Camp®, hosts camps for caretakers and survivors of stroke (the “Camp” or “Camps”).

I hereby Authorize United Stroke Alliance (“USA”) to use, publish, and/or otherwise disclose my Individual Identifiable Information, which includes but is not limited to: my name, image and likeness, voice and/or picture (my “Information") as described below. This authorization is voluntary, and no individual has coerced or forced me into agreeing to this authorization.

I understand that USA may benefit, monetarily, non-monetarily, or otherwise, from the use of my Information. I understand that I will not be entitled to any compensation for use of my Information, and I specifically release all claims against USA for the same. I understand that once my Information is received by USA, that it may be subject to use, publication or disclosure. I waive any claims of violations of federal, state, or local laws which are the result of said use, publication or disclosure.

A. Individual Identifiable Information includes, but is not limited to:

Pictures, sound recordings, videos or written statements containing my image, likeness or voice;
Interviews or statements by or about me; and
My medical situation and specific health information related to my participation in (for purposes of advancing the mission of) Camp.

B. Use and Media, my Information may be used

For publication in print, digital, or electronic media and in any other forms or forum; and
For inclusion on the USA or Camp website; and
For use in other promotional materials including by Camp sponsors and partners.

C. Right to Revoke

I acknowledge that I have the right to revoke this authorization in writing by contacting United Stroke Alliance. Any revocation will be prospective and not retrospective meaning USA will have no obligation to remove or edit out my Information from previously published media.

By checking the box below, I acknowledge and affirm the statements in this authorization for

Please check one:

I agree to the statements in the AUTHORIZATION FOR USE/OR DISCLOSURE OF INFORMATION

STROKE CAMP VOLUNTEER POLICIES AND PROCEDURES

Each 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).

Please read the following Practices and Policies Agreement CAREFULLY AND THOUGHTFULLY then sign the statement of the 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. Cell phones can be used during free time, but are to be kept silent during camp group activities. Cell coverage is spotty at many of our camp locations.

VALUABLES AND CASH: Everyone is urged not to bring highly valued clothing and accessories. The Camp cannot be responsible for loss or damage to person property.

PROFESSIONALISM: Confidential information given and received before, during, or after camp must be held in confidence. Volunteers must act professionally toward all campers.

SMOKING: Smoking on the camp grounds is forbidden and is extremely dangerous to the environment, and the health of you and those around you. If smoking is permitted, there will be a designated area to be used during your breaks.

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 dismissing a volunteer. 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.

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: Golf carts are for the purpose of transporting stroke survivors and caregivers between points at camp or moving equipment when necessary as well as for golf cart tours for the survivors and caregivers. 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 DRIVERS LICENSE IS PROHIBITED 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 departure.

I acknowledge 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.

I further acknowledge that my volunteer services will not entitle me to any employee benefits provided to RRSC employees. RRSC or its Representative may terminate my volunteer services at any time and for any reason, or without notice.

I have read the above Practices and Polices and agree to abide by the regulations established or the retreat. I am fully aware that adhering to the rules will be my sole responsibility. Deviation from these rules my be cause for immediate dismissal from Camp.

I, the undersigned, agree to the terms above.

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