Overnight Counselor Registration

General Information
Emergency Contact
Health Information
Consent Agreements
Medications
Submit your Form

Url

New or Returning Couselor? *

Prefix

First Name *

Last Name *

Nick Name

Street Address *

Supplemental Address

City *

State *

Zip Code *

Email *

Home Phone

Mobile Phone

Birthdate *

You must be at least 16 years old to volunteer.

Gender

Volunteer Organization/School/Church/Business/Club

If you are part of a organization, select it here.

New Organization

If your volunteer organization is not listed, enter it hear and we will add it to our list.

Volunteer Start Date

Please validate or enter the date when you first began as a volunteer with Faces of Courage. Estimates are ok!

Proceed to Emergency Contact Tab

Emergency Contact

First Name

Last Name

Relationship

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone

Secondary Phone

Proceed to Health Information Tab

Health Information

Clinic

Clinic/Hospital where you receive care

Physician/Nurse Practitioner Name

Physician/Nurse Practitioner Phone

Medical Issues

(Seizures, diabetes, asthma)

Allergies

(medications, food, plants, insects)

Diagnosis

Diagnosis Date

In Therapy/Treatment *

Yes

Relapse Date

Bone Marrow Stem Cell Transplant? *

Yes

Infectious Diseases

Food Restrictions

Physical Restrictions

Other Information

Proceed to Volunteer Agreements Tab

Consent Agreements

Medical Consent *

I (We) hereby acknowledge that the activities associated with any recreational program involves an element of risk of injury. These activities include but are not limited to: swimming, canoeing, softball, volleyball, climbing, hiking, basketball, arts and crafts. Faces of Courage Foundation does not own, operate or control the facilities where life enrichment activities are conducted. As a consequence, the below signed hereby acknowledges that he/she does hereby assume the risk of any injury, illness, harm or damage of any type that may occur in the course of his/her own personal or his/her child’s participation in any Faces of Courage Foundation program and release Faces of Courage Foundation and its board, Officers, venue, Staff and Volunteers from any liability or responsibility whatsoever.

Treatment Consent *

I (We) give permission to the medical personnel selected by the program director to order x-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange related transportation for myself or child due to injury, illness or medical emergency. In the event that I cannot/ or any other appointed individual cannot be reached in an emergency, I hereby give permission to the physician selected by the program director to secure and administer treatment, including hospitalization, for the above named individual.

Media Participation *

I (We) grant permission for the above named to participate in any audio-visual, photo, interview, or multi-media event that may take place by Faces of Courage Foundation and I (we) release everyone involved from liability or claims in association with said coverage.

Media Release *

I (We) grant permission for any photos, audio-visual footage, interviews both recorded and printed of the above named individual, to be used for publication in any multi-media or advertising format, such as brochures, websites, television, public service announcements, ads and publications with the express purpose of marketing and promoting Faces of Courage Foundation.

Agreement Date *

By entering today’s date, I certify that I have read and agree to the agreements listed above. This agreement will be subject to renewal each year I am a volunteer for Faces of Courage.

Overnight Counselor Registration

Proceed to Emergency Contact Tab

Emergency Contact

Proceed to Health Information Tab

Health Information

Proceed to Volunteer Agreements Tab

Consent Agreements

Proceed to the Medications Tab

Medications List

Proceed to Submit Tab

Submit your Form