Stem Camp_Staff Health History Form

YOUTH CAMP HEALTH HISTORY STAFF MEMBER/VOLUNTEER

Ensure all information is completed

Name

Current Residence

EMERGENCY CONTACT INFORMATION:

Emergency Contact Person

Phone

Format: (000) 000-0000.

Primary Care Physician or other provider of medical care

Phone

Format: (000) 000-0000.

HEALTH INFORMATION:

Are there any pertinent health problems including physical, psychiatric, or behavioral problems of which we need to be aware?

If Yes, Explain:

Are there any medications, dietary restrictions, allergies, or special needs of which we need to be aware?

If Yes, Explain:

IMMUNIZATION INFORMATION:

Must list current residence above.

For staff members/volunteers who currently reside WITHIN the United States, a United States territory, or the District of Columbia: Do you have any immunization exemptions because of a parental or guardian objection or medical contraindication?

If Yes, List:

For staff members/volunteers who reside outside the United States, a United States territory, or the District of Columbia: Attach record of vaccination or immunity on Department form MDH-896.

If Applicable, Upload Form MDH-896 Here:

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Staff Member/Volunteer Signature or Parent or Legal Guardian's Signature (If Staff Member is Under 18 Years):

To Sign Type In Your Name Below:

Date