Camp Sweeney
Serving Children with Diabetes for More than 70 Years
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Annual Disclosure for Full Time Staff
2022
Fantastic Summer - Second Session
Starts In
Employee Annual Disclosure Statement
This form is for employees who have been continuously employed by Camp Sweeney, full time or part time, since last year.
If you have NOT been continuously employed, please return to the
Employee Documentation Page
to complete the appropriate paperwork.
In this form, we will ask you about your vehicle parking pass, direct deposit information (if any), health and insurance, and current drivers license and social security card. Please have this information on hand if any there are changes from last year.
Employee Name
*
First
Middle Initial
Last
Name you prefer to be called
*
Permanent Address
*
Where you will receive your W2 in January.
Street Address
City
State
Zip
Email
*
Phone
*
Tee Shirt Size
*
Adult Small
Adult Medium
Adult Large
Adult X-Large
Adult XX-Large
SOCIAL SECURITY CARD: upload if name has changed
Max. file size: 195 MB.
DRIVER'S LICENSE: upload if new name, address, expiration
Max. file size: 195 MB.
General Health Information
Please let us know about any recent medical issues, restrictions or limitations, drug or food allergies.
Personal physician and telephone number
*
INSURANCE CARD: upload front and back sides if insurance changed
Drop files here or
Select files
Max. file size: 195 MB.
Emergency Contacts
Primary Contact Name
*
Primary Contact Phone
*
Primary Contact Relationship
*
Spouse/Partner
Mother
Father
Sister
Brother
Friend
Other
Secondary Contact Name
*
Secondary Contact Phone
*
Secondary Contact Relationship
*
Spouse/Partner
Mother
Father
Sister
Brother
Friend
Other
UPDATED Immunizations and Physical Exam
List Dates MO/YEAR, for example 04/2016
Latest Tetanus Shot (must be within last 7 years)
*
Latest COVID-19 booster (must be within last 12 months)
*
Date of last physical exam, must be within last 2 years
*
Voluntary Disclosure Statement
Have you ever been arrested or convicted of ANY crime, including sex related or child abuse offenses?
*
Yes
No
Details of offenses
Vehicle Information
Have you changed vehicles since last year?
*
Employee vehicles are required to be identified by a parking sticker.
No, I have not changed vehicles since last year.
Yes, I have changed vehicles and I need a new sticker.
Vehicle Make
*
Vehicle Model
*
Vehicle Year
*
Vehicle License Plate
*
Vehicle Color
*
Direct Deposit Authorization
Would you like to have your paycheck and reimbursements deposited directly into your bank account? This is a free service.
*
Yes
No
If you used direct deposit last year, is your bank information the same?
*
Yes, my bank information is the same.
No, my bank information is not the same.
N/A I did not use direct deposit last year, but I want to this year.
Bank Account Type
*
Checking Account
Savings Account
Bank Name
*
Bank City and State
*
Bank Account Number
*
Your bank account number is NOT the same as the 16-digit number on your debit card.
Bank Routing Number (9-digits)
*
Certifications, Authorizations, and Permissions
Acknowledgement
*
I certify
that I have received a copy of the pre-employment handbook.
I certify
that the facts included in this form are true to the best of my knowledge.
I authorize
any authorized employee or agent of Camp Sweeney and/or Southwestern Diabetic Foundation to investigate any of the facts I submitted in my employment documentation.
I authorize
any authorized employee or agent of Camp Sweeney and/or Southwestern Diabetic Foundation to perform criminal and civil background checks on me.
I give permission
to Camp Sweeney / Southwestern Diabetic Foundation to use my likeness or voice that may be obtained during my employment, interviews and/or orientation for the use of live and recorded internet broadcasts, internet pictures and videotapes in any of its publicity campaigns, websites, social media, and/or printed media.
I give permission
to any authorized employee or agent of Camp Sweeney and/or Southwestern Diabetic Foundation to treat me in the event of medical emergency.
I authorize
Southwestern Diabetic Foundation to make direct deposit payments to my bank account if I provided the appropriate documentation/information to do so.
I agree
to complete the state mandated safe-environment course provided by Camp Sweeney each year in order to recognize and prevent child abuse.
I agree to the certifications, authorizations, and permissions listed above.
*
Date
MM slash DD slash YYYY
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