Youth Camp Staff Medical Form

All YC Staff must fill out this Medical Form by Wednesday, June 12th.

Staff Member Name*

First Last

Email*

Church Attending:*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Primary Phone*

Gender*

Birthdate*

PRIMARY EMERGENCY CONTACT (Spouse/Other Adult)*

First Last

Primary Emergency Contact Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Number to be reached in an emergency*

Will the PRIMARY EMERGENCY CONTACT person be STAYING ON-SITE for the duration of camp?*

Yes
No

(Sleeping overnight in a tent or a pre-approval RV)

SECONDARY EMERGENCY CONTACT*

This adult can make decisions (medical or situational) if the PRIMARY EMERGENCY CONTACT cannot be reached. *DO NOT LIST A CAMP STAFF PERSON as a SECONDARY EMERGENCY CONTACT!

First Last

Cell Phone*

MEDICAL INFORMATION AND RELEASE

CONFIDENTIAL - We respect your privacy. This form is intended to provide necessary medical information to care for you. It will be solely utilized by the Medical Team staff. It may also be reviewed by medical personnel, camp administration, office staff, and transportation personnel.

If you have any medical questions, feel free to reach out to Lori Felizzi, our Youth Camp Medical Team Leader (717-344-4780).

STAFF MEMBER's HEALTH CARE PROVIDER/MEDICAL INSURANCE:

CHECK HERE IF UNDERINSURED/SELF-PAY

Physician's Name

First Last

Physician's Phone

Medical Insurance Carrier

Insurer's Phone

Policy #

Group #

STAFF MEMBER'S HEALTH HISTORY

ALLERGIES (check all that apply)*

NONE
Animals
Hay Fever
Insect Sting
Medication
Other (list below)

Animals (Indicate Severity)

Mild: No Medication required (ex: rash resolves on its own)
Moderate: Medication may be required (ex: Benadryl for hives)
Severe: Life threatening required to bring!

Animals

Please specify:

Hay Fever (Indicate Severity)

Mild: No Medication required (ex: rash resolves on its own)
Moderate: Medication may be required (ex: Benadryl for hives)
Severe: Life threatening required to bring!

Hay Fever

Please specify:

Insect Sting (Indicate Severity)

Mild: No Medication required (ex: rash resolves on its own)
Moderate: Medication may be required (ex: Benadryl for hives)
Severe: Life threatening required to bring!

Insect Sting

Please specify:

Medication (Indicate Severity)

Mild: No Medication required (ex: rash resolves on its own)
Moderate: Medication may be required (ex: Benadryl for hives)
Severe: Life threatening required to bring!

Medication

Please specify:

Other (Indicate Severity)

Mild: No Medication required (ex: rash resolves on its own)
Moderate: Medication may be required (ex: Benadryl for hives)
Severe: Life threatening required to bring!

Other

Please specify:

FOOD ALLERGIES & DIETARY RESTRICTIONS*

NO food allergies or dietary restrictions.
YES, I have food allergies or dietary restrictions.

Food allergy list

We need to know what foods cause what reaction and how dramatic the reaction is.
Please list food restrictions or allergies and any medical interventions necessary (epi-pen, Benadryl) in the space provided.

PLEASE NOTE: During mealtimes, you may choose accordingly from the foods served to ALL campers. There are NO SPECIAL MEALS made for those with food allergies. If you have special food you need to bring, YOU ARE RESPONSIBLE FOR PROVIDING REFRIGERATION IN THE FORM OF A COOLER.

DUE TO LIMITED SPACE, NO REFRIGERATION WILL BE PROVIDED BY THE CHURCH.

Tetanus Vaccinations

Have you had any Tetanus vaccinations (including DTap, TDap, or TD)? *Note: If Tetanus vaccination information is not supplied, your signature at the end of this form releases us from liability.

Have you received any Tetanus vaccinations in the last 10 years?*

*NOTE: If you're not sure, please wait to complete form until you are certain. Due to cuts/scrapes that may occur during YC, this information is really important.

NO
YES

Vaccination Type*

I have received the DTap vaccination.
I have received the TDap vaccination.
I have received the TD vaccination.

*NOTE: If you have received a Tetanus vaccination, it is imperative that we have the specific type/date of administration. If you don't have this information handy, please wait until you do before completing the form.

Date of vaccination*

CONDITIONS & DISEASES (check all that apply)*

Behavioral Issues - Please Specify:

Other - Please Specify:

Additional Comments

Comments / Questions

By signing below, I acknowledge that I have read, understood, and agree to the terms and conditions in the Release of Medical Liability and Adult Participation Agreements.

Signature*

Phone

This field is for validation purposes and should be left unchanged.