1. Retreat and Refresh Stroke Camp
Camp Menno Haven, Tiskilwa, IL
September 10-12, 2010
You are completing this form to be a volunteer of Retreat and Refresh Stroke Camp (hereafter “Camp”) for
the weekend sponsored by Illinois Neurological Institute, Peoria, IL. Please complete all requested
information in each section. Volunteers are required to be at least 20 years of age and be in good health. It
is your responsibility to let us know if special accommodations need to be arranged. Healthcare background
or training welcomed, but not necessary. All information being collected for herein is solely to be used in
the event of a medical emergency. All information will be kept confidential during the event and after the
event all forms will be destroyed or returned. Return to:
Retreat and Refresh Stroke Camp Phone numbers
Marylee Nunley, Camp Director 309-645-9258 or 309-693-2375
425 W. Giles Lane
Peoria, IL 61614
City: ______________________________ State: _______________ Zip __________________
Birth date: ____________ Sex_____________ Shirt Size _______________________
Occupation: _________________ Degree (if applicable) _____________________________
Brief Employment Experience: (Include position, employer, and dates employed)
Camp Experience: (Brief History if applicable)
List Areas of Training, special skills and interests:
Arts and Crafts
Sports, Games, Athletics
Discussion Groups or Education
2. Please give any other activities you could organize or help with for stroke survivors and/or
Please list any equipment you could bring to the camp.
Do you have concerns/limitations about assisting individuals with eating, game playing, or other
activities at camp? Yes No If yes please describe:
Please list any current certifications or credentials you have which would be helpful in the camp
First aid Other
Please list any other information about yourself that you wish to share:
3. Volunteer Policies and Procedures
Each member of the Retreat and Refresh Stroke Camp (hereafter “Camp”) staff: counselors, activity
staff, medical staff, and administrative staff has a responsibility to provide for and protect the health
and well being of campers (stroke survivors and their caregivers).
Please read the following Practices and Policies Agreement carefully and thoughtfully then sign the
statement of compliance that follows.
Medical Services: The medical staff must be advised promptly of any injuries or health
problems. All volunteers must follow decisions made by camp medical staff for themselves and
campers. Everyone must turn in a completed Camp Physical Form prior to camp.
Telephone Calls: Volunteers will not be paged for calls, except in case of emergency. The
office phone cannot be used for personal calls. Cell phones can be used during free time, but are
to be kept silent during camp group activities.
Valuables and Cash: Everyone is urged not to bring highly valued clothing and accessories.
The Camp cannot be responsible for loss or damage to personal property.
Professionalism: Confidential information given and received before, during, or after a camp
must be held in confidence. Volunteers must act professionally toward all campers.
Smoking: Smoking on the camp grounds is forbidden and is extremely dangerous. If smoking is
permitted, there will be a designated area to be used during your breaks.
Alcohol and Drugs: The use of alcoholic beverages or illegal drugs is strictly forbidden and will
be considered grounds for sending a volunteer home. To be under the influence of alcohol or
drugs while caring for campers is not consistent with a volunteer’s responsibility to the campers.
Medical staff or the Camp Director can release anyone who is under the influence during the
I acknowledge that I am volunteering to perform services for camp, with no expectation of pay or
remuneration of any kind. I understand that I will not be employed by or be an employee of camp.
Because I will not be an employee, I understand that I will not be covered by either state
unemployment or state workers’ compensation laws or any camp insurance policy.
I further acknowledge that my volunteer services will not entitle me to any employee benefits
provided by camp to its employees. Either I or camp may decide to terminate my volunteer services
at any time and for any reason, with or without notice.
I have read the above Practices and Policies and agree to abide by the regulations established or the
retreat. I am fully aware that adhering to the rules will by my sole responsibility. Deviation from
these rules may be cause for immediate dismissal from the Camp.
Signature of Volunteer Date
4. Illinois Neurological Institute
September 10-12, 2010
Camp Menno Haven, Tiskilwa, IL
Volunteers are expected to arrive mid-day on September 10, and depart at approximately 2:00
pm on Sunday, September 12, 2020. There is some preliminary work to be done to get things set
up for the weekend and a volunteer training will take place prior to camper registration. Stroke
survivors and caregivers arrive between 2:30 and 4:00 on Friday and depart at the close of the
event. We ask that core volunteers plan to attend the entire retreat unless other arrangements
have been made.
We have need for some volunteers to make presentations or assist with special activities over the
weekend as well IE: crafts, educational presentations, fishing, golf, children’s activities, all camp
Please indicate your availability for the weekend.
September 10-12, 2010, Camp Menno Haven, Tiskilwa, IL
_________ Entire Weekend
Or: available beginning _______________date ____________________ am/pm through
date_________________ through ___________________am/pm
You will receive confirmation along with directions, what to bring, and a detailed schedule prior
to camp. If you have any questions about this form, please don’t hesitate to contact Marylee at
309-645-9258 or 309-693-2375.