staff health form

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.
Name*
First Last
Birthdate*
MM slash DD slash YYYY
Age
Phone
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Health Insurance Company
Policy Number
Emergency Contact Name
First Last
Emergency Contact Phone
Continuing Conditions
- Asthma
- Diabetes
- Sleepwalking
- Other(s)
Describe Other Condition(s)
Allergies (list all food and drug allergies)
Measles (MMR) Immunization*
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:
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