Health Form and Emergency Contact
Privacy notice: This information is needed to alert camp administration of the medical needs of the camp population. It will be treated as confidential medical information, and will be given to appropriate medical service providers in case of an emergency.
MM slash DD slash YYYY
Age Phone Home Address
Health Insurance Company Policy Number Emergency Contact Name
Emergency Contact Phone Continuing Conditions Describe Other Condition(s) Allergies (list all food and drug allergies) Measles (MMR) Immunization * Select one Yes No
Have you had 2 doses of MMR since you were born?
Medications to be taken at camp (Name/Dosage (if any))
Please bring medications in their
ORIGINAL CONTAINERS. Medications will have to be kept under lock and key through wellness or your own lockbox or locked car. No staff medications can be kept in rooms with campers.
Please provide a hard copy of your immunization records. If you cannot provide these records, you will be on the unimmunized staff list and may be sent home should exposure to measles occur. Additional comments/ concerns: Signature
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