CJ Adult Staff Health Form 2024

Camp Judah Health Form - Staff
This form MUST be accurately completed by all camp staff members over 18 years of age. (Staff members up to age 18 must submit the two-part Camp Judah Camper Health Form.) Please be certain you are in good health and up to the physical demands upon arrival at camp. We will be unable to safely accommodate some types of medical conditions.
Full Name
Gender
Date of Birth

MonthDayYear
Date
Address

Address

Street Address Line 2

CityState

Zip
Emergency Contacts

Please provide the name and information for two (2) emergency contacts
Name
Relationship to staff member
Phone
Name
Relationship to staff member
Phone
Health Insurance Information
Carrier
Phone Number
Please enter a valid phone number.
Policy No.
In whose name?
Immunizations

Please provide us with a copy of your immunization record.
Please add information concerning any pertinent health history. (ie, diabetes, heart seizure, etc)
Name of Personal Physician
Phone Number of Personal Physician
Allergies

Please list ALL known allergies
Food
Medications
Hay Fever
Insect bites/stings
Other
Do you have an epipen you plan to have with you at camp
List any additional food or activity restrictions
Medications

Please list ALL medications taken regularly, including over the counter or nonprescription drugs. If necessary, additional pages can be faxed or emailed

Rows	Medication	Dosage	Specific times taken each day	Purpose
1
2
3
4

IMPORTANT

Keep all medication in the original and current packaging/bottle that identifies the prescribing physician, the name of the medication, the dosage, the frequency of administration and purpose. Be sure to bring enough medication to last the entire time at camp.
Authorization to treat: This health form is correct so far as I know, and I am able to engage in all camp activities except as noted on this form. If I cannot give consent, I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for myself. I also authorize the camp nurse to administer treatment as necessary and to administer any medications prescribed by my physician as listed on this form.
Signature
Date

MonthDayYear
Date
This form must be fully & accurately completed and submitted prior to the onset of camp.

Admin. Address: CAMP JUDAH 2444 N Main St., Warsaw, NY 14569

Email: campjudah@gmail.com

Regular Fax (except during week of camp): 585-786-8249

Fax during week of camp only: (June 29 – July 5, 2024): 585-687-4624
Should be Empty:

Camp Judah Health Form - Staff

Emergency Contacts

Health Insurance Information

Immunizations

Allergies

Medications

IMPORTANT