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Fire Prevention
- Programs
- Resources
Burn Survivors
Our Impact
Get Involved
About Us
- Our Mission
- Our Team
- Contact Us
- News
- Financials

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Family Retreat Volunteer Application

Thank you for your interest in volunteering at our 2019 Family Retreat!

WHEN: April 26-28, 2019, 1:00 PM check-in

WHERE: Island Palms Hotel & Marina

ALL FOOD AND LODGING IS PROVIDED: Volunteer Training will take place on April 17 or April 20. Choose one that works for you!

MISSION: To provide a safe, supportive, and inclusive environment for families impacted by burn injury.

In addition to filling out this application please:

Attend a volunteer screening interview at the Burn Institute (new volunteers only)
Send your resume to Lstone@burninstitute.org (new volunteers only)
Complete a LiveScan (new volunteers only)
Attend a Volunteer Training on one of these dates: April 17 (Wed) or April 20 (Sat) 10:00 – 12:30 pm both dates (lunch will be provided)

Step 1 of 9

11%

Part I. Volunteer Information
Name
First Last
Mailing Address
Street Address City State / Province / Region ZIP / Postal Code
Email Address
Date of Birth
MM
DD
YYYY
Phone Number
Occupation
Have you ever worked with burn survivors before?
- Yes
- No
Are you a new or returning volunteer for this retreat?
- New
- Returning
What area are you interested in volunteering for at Family Retreat? (check all interests)

Part II. Medical History/Health Insurance Information
Health Insurance Provider
Primary Care Physician
Please list any allergies to medication or food.
Do you have any physical limitations or medical concerns? If so, please describe.

Part III. Certifications/Skills
Are you CPR/AED certified?
- Yes
- No
CPR/AED Certification Expiration
MM
DD
YYYY
CPR/AED Certification Type
Are you First Aid certified?
- Yes
- No
First Aid Certification Expiration
MM
DD
YYYY
Do you have any other certifications that are applicable to this retreat?

PART IV. Personal Background History
Have you ever been convicted, fined, place on probation or imprisoned?
- Yes
- No
Have you ever been accused of, convicted or of in any other way been involved in an allegation of a crime involving a child?
- Yes
- No
Have you ever been found liable for civil penalties or damages involving sexual or physical abuse of a child or children?
- Yes
- No
Are you now or have you ever been subject to any court order involving the sexual or physical abuse of a minor, including, but not limited to a domestic protection order or the termination of parent(s) guardian(s) rights?
- Yes
- No
I UNDERSTAND THAT:
1. If circumstances are discovered that would indicate a 'yes' answer to any of the above questions, consideration to participate may be terminated immediately. 2. Please note that the Burn Institute will conduct background checks, to include Department of Justice, FBI as well as the National Sex Offender Public Website.3. The camp may terminate participation of any person that is found regardless of when discovered, to have:a. A history of complaints of abuse or neglect towards a minor;b. Resigned, been terminated or been asked to resign from a position whether paid or unpaid, due to complaint(s) of sexual abuse of a minor; and/orc. Falsified or omitted information in this disclosure statement.
INITIAL

Part V. Emergency Contact Information
Name
First Last
Phone Number
Relationship to You

Part VI. Image, Video, and Information Release
WE REQUEST YOUR PERMISSION TO FILM, PHOTOGRAPH OR INTERVIEW YOU TO HELP OUR EFFORTS IN INCREASING PUBLIC AWARENESS AND SUPPORT OF OUR PROGRAMS BY APPEARING IN PHOTOGRAPHS, VIDEO OR OTHER PUBLICITY THAT THE RETREAT MAY PRODUCE.
Please Check Below
- I DO AUTHORIZE THE BURN INSTITUTE TO USE PHOTOGRAPHS, VIDEOTAPES AND/OR INTERVIEWS OF ME TO FURTHER THEIR EFFORTS TO PROMOTE PUBLIC AWARENESS AND SUPPORT
- I DO NOT WISH TO BE PHOTOGRAPHED/INTERVIEWED

Part VII. Behavior Agreement
ALL STAFF/VOLUNTEERS WILL BE RESPONSIBLE FOR ADHERING TO ALL RULES AND REGULATIONS SET FORTH BY THE ISLAND PALMS HOTEL, BEST WESTERN, & THE BURN INSTITUTE.
INITIAL

Part VIII. Mandatory Training Dates
Prior to family retreat we will host a mandatory training for all staff/volunteers.
Please check all dates you are available for the mandatory training session.

THANK YOU!
We will be in touch about further steps! If you have any questions, please contact Leilani at Lstone@burninstitute.org or 858-541-2277.

San Diego, CA

8825 Aero Drive, Suite 200
San Diego, CA 92123

P. (858) 541-2277

F. (858) 541-7179

Imperial Valley, CA

612 J Street, Suite 3
Imperial, CA 92251

P. (760) 355-3175

F. (760) 355-0836

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