Staff Medical Information Form
Crossroads Christian Camp
Staff member Name
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Age
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent or Guardian's Name (If under 18)
First Name
Last Name
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Other Emergency Contacts
First Name
Last Name
Other Emergency Contacts Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Other Emergency Contact (2)
First Name
Last Name
Other Emergency Contacts Phone (2)
Please enter a valid phone number.
Format: (000) 000-0000.
Date of most recent Tetanus booster
-
Month
-
Day
Year
Date
Are all other immunizations up to date?
Yes
No
A copy of the immunization records must be submitted.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Allergies (list Food/Environment/Drug allergies including the reaction.)
Medications presently taking (prescriptions, over-the-counter, vitamins, creams, ointments). Drug name and reason taking.
Does staff member have
Asthma
Diabetes
Seizures
Any medical, emotional, or physical disorder which could affect participation in camp activities? If yes, please explain:
Height & Weight (Any Hospitalizations, if so please explain)
Name/Phone of family Physician:
(Under 18) Parental Authorization: This information is correct so far as I know and the child herein described has permission to engage in all camp activities, except as noted by me and/or an examining physician. I give my permission for routine medical treatment to be administered by the camp medical personnel to the above named camper/staff. In the event I cannot be reached, I give permission for camp personnel to obtain emergency transportation & emergency medical treatment for the health of my child named above. I will not hold Crossroads Christian Camp liable for the consequences of the reasonable exercise of authority by camp medical personnel so long as treatment is given in good faith with the best interest of my child in mind.
Parent Signature
Submit
Should be Empty: