Medical Form

Medical Form

In case of emergency Chv”sh we need to be aware of any medical information. This will be kept completely confidential.

Medical Information
Preferred Emergency Contact*
Doctor*
Do you have any physical health medical history we should be aware of, if yes please specify:*
Do you have any mental health medical history we should be aware of, if yes please specify: *
Are you currently on any medication/inhaler, if yes please specify:*
Are you allergic to any foods, medication or other, if yes please specify: *
If you carry an epipen please note it here so we can speak to you about it regarding any concerns
Please note the date of your last tetanus shot*

MonthDayYear
Date
Please check off any conditions that apply to you:

AsthmaHeart conditionDiabeticSurgery in the last yearInjury in the last yearAnxiety
If there is anything else we should be aware of please state it here: *

Consent
PLEASE NOTE: IF YOU ARE ACCEPTED TO CAMP YEKA GIRLS AS A STAFF MEMBER YOU WILL NEED TO SUBMIT THIS FORM A SECOND TIME WITH A SIGNATURE FROM YOUR DOCTOR.
I undertake to update any information that changes prior to camp. In a case of emergency, I (the undersigned) authorize Menucha Hanoka to relate the above mentioned information as deemed necessary. *

Clear
Name*
Date*

MonthDayYear
Date
Legal Guardian's Signature (for under 18’s only)

I am under 18
Legal Guardian's Info
Legal Guardian's Signature

Clear
Should be Empty: