Rainbow's End Volunteer Consent & Disclosure Form

Volunteer Consent & Disclosure Form

Rainbow's End Day Camp
This form obtains a signature authorization for the following:
- Consent Agreement & Terms
- Background Investigation
- Background Check & Release of Information
- Health History Form
- TB Questionnaire
Volunteer Name:*

First NameLast Name

Consent Agreement & Terms

Please read statement below.
Participant age:*

17 years old or younger18 years old or older
If you are 17 years or younger, please have your parent/guardian sign this section.

I give my son/daughter (NAMED ABOVE) permission to work as a volunteer at Rainbow’s End. I also give permission for my child's name/or photograph to be used for promotional purposes or any media use concerning Rainbow's End.

I give permission for my son/daughter to have necessary labratory tests, health assessment, and other screenings as needed for volunteering at Aspirus. Testing may include a labrotory test blood draw for TB, measles, mumps, rubella and chicken pox. Follow up vaccines will require individual consent. The above testing requirements follow hospital policy based on Center for Disease Control and Joint Commission standards.

I recognize that certain hazards and dangers are inherent in the camp program, particularly but not limited to, the activities of archery, and swimming. I acknowledge that although Rainbow’s End and Samoset Boy Scouts Council have taken safety measures to minimize the risk of injury to camp participants, they cannot ensure nor guarantee that the participants, equipment, premises and/or activities will be free of hazards, accidents and/or injuries. By participating in the program, I assume responsibility and release Aspirus Wausau Hospital and Samoset Boy Scouts Council from liability and waive any claims against them arising from any such injuries to my child.
If you are 18 years or older, please sign this section.

I give permission to have necessary labratory tests, health assessment, and other screenings as needed for volunteering at Aspirus. Testing may include a labrotory test blood draw for TB, measles, mumps, rubella and chicken pox. Follow up vaccines will require individual consent. The above testing requirements follow hospital policy based on Center for Disease Control and Joint Commission standards.

I give my consent to have my name and/or photograph used for promotional purposes or any media use concerning Rainbow’s End.

I recognize that certain hazards and dangers are inherent in the camp program, particularly but not limited to, the activities of archery, and swimming. I acknowledge that although Rainbow’s End and Samoset Boy Scouts Council have taken safety measures to minimize the risk of injury to camp participants, they cannot ensure nor guarantee that the participants, equipment, premises and/or activities will be free of hazards, accidents and/or injuries. By participating in the program, I assume responsibility and release Aspirus Wausau Hospital and Samoset Boy Scouts Council from liability and waive any claims against them arising from any such injuries to myself.
Parent Signature (volunteer 17 years old or younger):

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Volunteer Signature (over 18 years old):

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Background Investigation

Please read statement below.
By signing below, I acknowledge receipt of the following separate documents (and certify that I have read and understood them):
- NOTICE REGARDING COMSUMER REPORTING ON YOU;
- ADDITIONAL STATE LAW NOTICES;
- A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT;
By signing below, I also authorize Aspirus Health to obtain "consumer reports" about me for employment purposes at any time during the hiring process and throughout my employment, if applicable.

To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information services bureau, employer, insurance company or other party to furnish any and all background information requested by CrimminalRecordCheck.com (CRC), PO Box 90998, Raleigh, North Carolina, 27675; 800-272-0266; www.CrimminalRecordCheck.com ("the Agency"), another outside organization acting on behalf of Aspirus Health, and/or Aspirus Health itself.
Parent Signature (volunteer 17 years old or younger):

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Volunteer Signature (over 18 years old):

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Background Disclosure & Release of Information

Please read statement below.
All positions at Aspirus and Aspirus' affiliated private practice groups require a comprehensive background check. Accordingly, Aspirus will be conducting a background check including an investigative report as defined in the Fair Credit Reporting Act. (Please note that Aspirus will conduct a background check only and does not include a credit check.) The background check will include court records, driving history, etc. As a result, the additional informaiton on this forn is needed to continue the employement application process. Aspirus may utilize a professional, certified reporting agency to retrieve necessary information and prepare such a reports.

This authorization, in original or copy form, shall be valid for this and any future reports or updates during the application process.
Birth Date*

MonthDayYear
Social Security Number: *
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Parent Signature (volunteer 17 years old or younger):

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Volunteer Signature (over 18 years old):

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	Yes	No
Do you have any physical or mental limitations which will require accommodations to allow you to volunteer?
Do you have any permanent restrictions related to a medical condition, surgery or injury?
Do you currently have a communicable or infectious disease?

	Yes	No
Have you ever had a rash or an allergic reaction after using latex products?
Have you ever had an allergic reaction that required epinephrine?
Do you have seasonal allergies that require medication?
Have you ever been treaded for dizziness, fainting spells, epilepsy or severe headache?

	Yes	No
Do you have a vision impairment (including color vision) that cannot be corrected by wearing glasses or contacts?
Can you see the regular print in newspapers, magazines or books (using glasses/contacts if needed)?
When you are walking in the street, can you see the "walk" sign and street names (using glasses/contacts if needed)?
Are you able to differentiate the colors on a traffic light?

	No	Yes
A persistent unexplained productive cough for 3 or more weeks AND
Blood in sputum or coughing up blood?
Fever (with unknown cause)?
Night sweats - unrelated to menopause (you wake up at night sweating)?
Unexplained weight loss or loss of appetite?
Fatigue (with unknown cause)?

	No	Yes
To your knowledge, while employed this past year, did you provide medical care for or become exposed to an individual with known active tuberculosis disease?
To your knowledge, have you ever had an exposure to an individual with known active tuberculosis disease in the community setting this past year?
Travel (for >1 month) or residence in a country with high TB prevalence. This includes any country OTHER THAN the US, Canada, Australia, New Zealand, or a county in western or northern Europe.
Night sweats - unrelated to menopause (you wake up at night sweating)?
Unexplained weight loss or loss of appetite?
Fatigue (with unknown cause)?
Current immunosuppression including receipt of an organ transplant, TNF alpha antagonist, chronic/high dose steroids (equivalent of prednisone >15 mg/day for >1month), HIV, diabetes or cancer.

Volunteer Consent & Disclosure Form

Consent Agreement & Terms

Background Investigation

Background Disclosure & Release of Information

Health History

Tuberculosis (TB) Symptom Questionnaire & Risk Assessment