Survey - 2023 Summer Camp Counselor Application (Returning) - Humane Society of Missouri

1.

Please tell us about YOU! Enter camp counselor's information.


*	First Name: Required
*	Last Name: Required
*	Email: Required
*	Street 1: Required
	Street 2:
*	City: Required
*	State / Province: Required
*	ZIP / Postal Code: Required
*	Phone Number: Required
*	Date of Birth: Required	Date of Birth:
	Yes, I would like to receive e-mail from Humane Society of Missouri - http://www.hsmo.org
	Yes, I would like to receive postal mail from Humane Society of Missouri - http://www.hsmo.org
	Keep me logged in. What's this? Remembers your login information for your convenience. Use only on trusted, private computers. Privacy Policy

*2.

Question - Required - Please list any allergies, medical conditions, IEPs, or any unique needs we should be aware of, or type NONE.

*3.

Question - Required - Please enter T-shirt size:

*4.

Question - Required - Are you available on Tuesday, June 6, 2023 from 9am-3pm for the required Camp Counselor Orientation taking place at our headquarters building at 1201 Macklind Ave?

*5.

Question - Required - No. of years you've been a Kids for Critter Camp Counselor:

(Maximum response 255 chars, approx. 5 rows of text)

*6.

Question - Required - Do you share your home with pets? If so, what kind of pets and what are their names?

(Maximum response 255 chars, approx. 5 rows of text)

We would like each counselor to be immersed in at least 2 full weeks of camp. Please let us know your availability.

*7.

Question - Required - Week-long Kids for Critters Camps are offered (9am-3pm Mon-Fri) this summer, and we would need you to be available from 8:30am-3:30pm each day of the week for the chosen camp. Please check the week-long camp(s) are you available. (Minimum 2 weeks, we would prefer 3 weeks)
Please make between 2 and 7 selections from the choices below.

	Week 1 June 12-16 (Ages 12-14)
	Week 2 June 26-30 (Ages 9-11)
	Week 3 July 10-14 (Ages 6-8)
	Week 4 July 17-21 (Ages 12-14)
	Week 5 July 24-28 (Ages 9-11)
	Week 6 July 31-Aug 4 (Ages 6-8)
	Week 7 Aug 7-11 (Ages 9-11)

In return for being allowed to participate at the Humane Society of Missouri, I release and agree not-to-sue the Humane Society of Missouri, its employees, sub-contractors, sponsors and affiliates from all present and future claims that may be made by me, my family, estate, heirs, or assigns for property damage, personal injury, or wrongful death arising as a result of my participation and caused by the ordinary negligence of the parties listed above, wherever, whenever, or however the same may occur. I understand and agree that those listed above are not responsible for any injury or property damage arising out of my participation, even if caused by their ordinary negligence. I understand that my participation involves certain risks, including, but not limited to, serious injury and death. I am voluntarily participating at the Humane Society of Missouri with knowledge of the danger involved and agree to accept all risks of participation and all related activities. I agree to let the parties use my name, likeness, and demographic information free of charge in any manner for any purpose. I understand that this document is intended to be as broad and inclusive as permitted by the laws of the state of Missouri and agree that if any portion of this Agreement is invalid, the remainder will continue in full legal force and effect. I further agree that any legal proceedings related to this waiver will take place in St. Louis, Missouri.

WAIVER AND RELEASE OF LIABILITY AUTHORIZATION AND CONSENT

I hereby give and grant to the Humane Society of Missouri, its employees, nominees, agents, successors and assigns, unlimited authorization, consent and permission to publish, republish, reproduce, distribute and, in any other manner, to use, any and all information about participant (excluding medical information) and any and all reproductions of their likeness (photographic or otherwise) and of their voice, whether or not related to any affiliation or association with the Humane Society of Missouri, and with or without the use or disclosure of participants name. I understand and agree that the authorizations, consents and permissions contained herein are given voluntarily and with the full understanding that no compensation or other payment of any kind will be paid to participant or to any other person for any of the agreements contained herein or for the exercise or use by the Humane Society of Missouri of any of the authorizations, consents or permissions granted in this Waiver and Release of Liability Authorization and Consent. I am of legal age and am freely signing this agreement on behalf of myself. I have read this form and understand that by signing this form, I am giving up legal right and remedies on behalf of myself, my family, estate, heirs, and/or assigns. I hereby consent and agree to the foregoing Waiver and Release of Liability Authorization and Consent for myself and I hereby give and grant the Humane Society of Missouri the authorizations, consents and permissions stated in the foregoing Waiver and Release of Liability Authorization and Consent, upon the terms and conditions stated therein.

*8.

Question - Required - By submitting my application, I understand that acceptance into the Humane Society of Missouri's Teen Volunteer program is not guaranteed. I acknowledge that I have read and fully understand the terms and conditions of the foregoing release.

Parent or Legal Guardian of Teen Volunteers Younger Than 18 years of age

I am the parent/legal guardian of the participant. I am of legal age and am freely signing this Waiver and Release of Liability Authorization and Consent on behalf of the participant. I hereby give my consent to allow participant to volunteer for the Humane Society of Missouri. I have read this form and fully understand that by signing this form, I am giving up legal rights and remedies on behalf of myself, the participant, and his/her family, estate, heirs, and/or assigns. As parent/legal guardian of the participant, for myself and for and on behalf of said participant, I hereby consent and agree to the forgoing Wavier and Release of Liability Authorization and Consent, and for myself and for and on behalf of said participant, I hereby give and grant the Humane Society of Missouri the authorizations, consents and permissions stated in the foregoing Wavier and Release of Liability Authorization and Consent, upon the terms and conditions stated therein.

*9.

Question - Required - I, the parent/guardian of applicant, give my consent to allow applicant to volunteer for the Humane Society of Missouri

*10.

Question - Required - Name and Phone Number of Parent/Guardian

(Maximum response 255 chars, approx. 5 rows of text)