2015 BAE Vet Camp Counselor Program & Application

Name

SSN

Date of Birth:

Age as of 8/1/15:

Academic Resume: (PDF)

Copy of Driver's License: (JPEG)

Address

Phone

E-mail

What college do you attend?

What is your major?

Do you speak other languages besides English? If Yes, please list other languages:

Do you have youth camp experience? Please describe.

While equine experience is not necessary, do you have equine and/or veterinary medicine experience?

Why are you interested in becoming an Equine Vet Camp counselor?

Are you considering veterinary school?
---YesNo

Do you need to earn practical and clinical volunteer hours working with a veterinarian for your vet school application?

How would volunteering at BAE Vet Camp help you reach your academic or career goals?

Did you attend summer camp as a child?
---YesNo

On a scale of 1–10 (where 1 is the lowest, and 10 is the highest), what is your level of commitment to 2015 BAE Vet Camp? Are you committed to serving as a camp counselor all day, every day, for the week of August 1–7, 2015, 8am–5pm? Do you anticipate conflicts with that schedule?

Is there anything else you would like to share about yourself, your interest in veterinary medicine camp, and/or your camp counselor qualifications?

First Name (required)

Last Name (required)

Email (required)

Phone Number (required)

Street Address

City

State

Zip Code

First Name (required)

Last Name (required)

Birthdate (required)

Grade in Fall 2015 (required)

School (required)

Emergency Contact Name (required)

Relationship to Student (required)

Emergency Contact Phone (required)

Physician's Name

Physician's Phone

Insurance Carrier

Physical/Cognitive special needs or challenges? (required)

N/A if none.

Activities limited by physician? (required)

Any allergies, including food? (required)

Asthma? (required)

---YesNo

If yes to any of the above, please give us additional details and instruction.

Does you/your student use an EpiPen? (required)
---YesNo

Does you/your student use an asthma inhaler? (required)

---YesNo

Currently taking medication?

---YesNo

If yes to any of the above, please give us additional details and instruction.

Anything we need to know to ensure the safety of you/your student? (ex. custodial issues, phobias, etc.)?

Anything we need to ensure the most enjoyable experience for you/your student?

Riding Level:

---BeginnerIntermediateAdvanced

Riding Style:

Interested in Veterinary Medicine?

---YesNo

If you are interested in Veterinary Medicine, Please tell us about your past experiences in the Veterinary field:

T-Shirt Size:

---Youth SmallYouth MediumYouth LargeYouth XLSmallMediumLargeXL

Do you own a horse?

---YesNo

At which stable do you ride?

Interested in joining BAE Club?

---YesNo

How did you hear about us?

If you saw a flyer, where was it located?

Authorized Individuals

BAE Club staff is authorized to release my student into the care of the following people. Please provide the name, relationship to student and contact phone number for each individual.

My student has my permission to accompany Bay Area Equestrian Club, its camp counselors, mentors and its agents on all club sponsored field trips during camp. I understand that I will be notified in advance of any special instructions. Unless otherwise notified, students are to wear the BAECamp t-shirt on all field trips.

YesNo

Swimming:

My student is a swimmer:

---YesNo

Permission to swim:

---YesNo

Medical Policy (required)

---I AgreeI Do Not Agree

I have read, understand and agree to the Medical Policy.

Allergy Policy (required)

---YesNo

I have read, understand and agree to the Allergy Policy.

Tetanus & Rabies Waivers (required)

---YesNo

I have read, understand and agree to the Tetanus and Rabies waivers.

Photo Release

I AgreeI Do Not Agree

I have read, understand and agree to the Photographic Release.

Application Agreement (required)

---I AgreeI Do Not Agree

I have read, understand and agree to the Application Agreement.

E-Signature:

E-Signature Date: