Staff Health Form 2025

Health Form 2025

For Staff at Camp Pineshore Bible Camp. Staff under 18 will need parent/guardian signature.
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Gender*

MaleFemale
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian(s) Info (If under 18)

With Legal Custody To Be Contacted First In Case of Illness or Injury
Name

First NameLast Name
Relationship to You
Preferred Phone Number
Please enter a valid phone number.
2nd Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact

To be contacted in case of emergency
Name*

First NameLast Name
Relationship to Staff
Preferred Phone Number*
Please enter a valid phone number.
2nd Phone Number
Please enter a valid phone number.
Email
example@example.com
2nd Emergency Contact

In Event Parent(s)/Guardian(s) Can't Be Reached
Name*

First NameLast Name
Relationship to You
Preferred Phone Number
Please enter a valid phone number.
2nd Phone #
Please enter a valid phone number.
Email
example@example.com

Diet/Nutrition
Check all those that apply*

I eat a regular, varied diet and is prepared to eat a variety of foods at camp.Vegetation of this type: Semi-vegetarian (no pork or beef)Vegetation of this type: Pesco (no pork, beef, or chicken)Vegetation of this type: Vegan (no meats, eggs, dairy)Vegetation of this type: Lacto-ovo (no pork, beef, chicken, seafood, or fish)Lactose-intolerant.Issues with foods containing gluten based ingredients.I have an anaphylactic reaction when this food is eaten
What are the food(s) that cause an anaphylactic reaction?*

Restrictions or Activities
Does you need any certain restriction or adaptions for serving at camp?*

I have understand my job description and feel the I can do my jobI have reviewed the program and activities of the camp and feel the camper can do my job with some adaptions.
Restrictions and Adaptations*

Medical Insurance Info
Are you covered by family medical/hospital insurance?*

YesNo
Insurance Company*
Policy Number*
Subscriber*
Insurance Company Phone Number*
Please upload a copy of your insurance card if appropriate, copy both sides of the card so information is readable.

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Medication(s)

Bring enough medication to last the entire week. Prescription medications MUST be in the original pharmacy containers with appropriate labels. Other over the counter drugs and preparations such as vitamins, allergy medications and other supplements MUST be in original container. All medication of staff this are for minors will be checked in and administered by the camp nurse.
Medications*

Staff WILL NOT take any daily medications while attending camp.Staff WILL take daily medications while at camp
Staff takes this number of medications daily*
Name of Medications 1*
Reason for Taking Medication 1*
Dose given at Breakfast
Dose given at Evening Meal
Dose given at Bedtime
Other Dose Needed
Date Started/Last Dose
Name of Medications 2*
Reason for Taking Medication 2*
Dose given at Breakfast
Dose given at Evening Meal
Dose given at Bedtime
Other Does Needed
Date Started/Last Dose
Name of Medication 3*
Reason for Taking Medication 3*
Dose given at Breakfast
Dose given at Evening Meal
Dose given at Bedtime
Other Doses Needed
Date Started/Last Dose
Name of Medications 4*
Reason for Taking Medication 4*
Dose given at Breakfast
Dose given at Evening Meal
Dose given at Bedtime
Other Doses Needed
Date Started/Last Dose
Name of Medications 5*
Reason for Taking Medication 5*
Dose given at Breakfast
Dose given at Evening Meal
Dose given at Bedtime
Other Doses Needed
Date Started/Last Dose
Name of Medications 6*
Reason for Taking Medication 6*
Dose given at Breakfast
Dose given at Evening Meal
Dose given at Bedtime
Other Doses Needed
Date Started/Last Dose
Name of Medications 7*
Reason for Taking Medication 7*
Dose given at Breakfast
Dose given at Evening Meal
Dose given at Bedtime
Other Doses Needed
Date Started/Last Dose

Additional Information on Medications
The following non-prescription medications are stocked in the Mobile Infirmary and can be requested from the Camp Nurse as needed.

• Acetaminophen (Tylenol)
• Ibuprofen (Motrin)
• Diphenhydramine (Benadryl)
• TUMS Antacid
• Generic Cough Drops
• Calamine Lotion
• Aloe and Sunscreen
• Neosporin Antibiotic Ointment and Cream
• Hydrocortisone Cream
Allergy and Asthma Information
Please note that the Camp does not routinely stock Epi-pens or inhalers. These must be provided in original containers along with a separate
written “allergy” or “asthma” plan. This is a set of detailed instructions agreed upon by you and your child’s physician outlining what steps should
be taken in an asthma attack and/or allergic reaction. Please include a list of your child’s symptoms to watch for and any specific symptoms unique
to your child.
Inhaler Use
It is Camp policy to have the Camp Nurse keep all inhalers and assist with use as needed. This includes maintenance as well as "rescue" inhalers. However, we understand that every child's need is differenent and are willing to discusee what works best for your child. If you child has allergies and/or asthma please contact the director prior to drop off so that can make camp staff aware of the situation and take any precautions as needed.
I have read the additional information on medications above.*

Yes

Mental and Emotional Health Information

Please answer all the questions below with yes and no. For any yes answers, please give more detail in the space provided.
Has you ever been treated for attention deficit disorder (ADD or ADHD)?*

YesNo
Please explain or provide more detail.*
Has you ever been treated for emotional or behavioral difficulties or an eating disorder?*

YesNo
Please explain or provide more detail.*
During the past year, have you seen a professional about any mental or emotional health concerns?*

YesNo
Please explain or provide more detail.*
Have you ever had a significant life event that continues to affect the camper's life? (Example: History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, and etc.)*

YesNo
Please explain or provide more detail.*

Physician Contacts
Name of Physician*

First NameLast Name
Office Number*
Please enter a valid phone number.
Name of Dentist

First NameLast Name
Office Number
Please enter a valid phone number.

Anything we have forgotten to ask?
Is there any additional information about the camper's health that you think important? Please Explain.

Staff Physical
Please upload a copy of a medical physical. This physical must be done within 18 months of camp start and indicate you are healthy enough to serve at Camp Pineshore*

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Immunization Records
Immunization requirements for children attending camp follow the Massachusetts school immunization requirements, as outlined in the Massachusetts School Immunization Requirements table, which reflects the newest requirement: meningococcal vaccine (MenACWY) for students entering grades 7 and 11 (on or after the 16th birthday, in the latter case; see the tables that follow for further details). Children should meet the immunization requirements for the grade they will enter in the school year following their camp session. Children attending camp who are not yet school aged should follow the Childcare/Preschool immunization requirements included on the School Immunization Requirements table.

If you have any questions about vaccines please contact the MDPH Immunization Program at 888-658-2850 or 617-983-6800.
Please upload a copy of your up to date immunization records. If you have a medical exemption, please upload the doctor's note for the exemption, along with any other immunization records. If there is a religious exemption to any or all immunizations please upload a letter from you or your parent/guardian that states in writing that a vaccine conflicts with your sincerely held religious belief along with any other immunization records.*

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Permission and Waiver
I hearby release and waive and claim against Camp Pineshore, Messiah Lutheran Church-Fitchburg-MA, the Lutheran Church Missouri Synod, their employees, directors, officers, volunteers, and servants, from any and all liablity arising from any illness, including but not limited to Covid-19, or injury suffer by my camper(s) during his/her/their actitvites at Camp Pineshore and at related off-site activities, and for any lost or stolen articles.

I hearby give permission for the use of photographs and/or video including myself or my child for camp or church publicity.
Name of self (Or parent/Guardian if under 18)*
Signature of Self (or Parent Guardian if Under 18)*

Clear
Date*

MonthDayYear
Date
Type a question

TransportationWaiver and Release of Liability
Transportation services to my child in conjunction with Camp Pineshore activities, I, on behalf of myself or my child, authorize Camp Pineshore and request that Camp Pineshore provide transportation services to my child in conjunction with camp activities, and hereby voluntarily release, waive, discharge, hold harmless, defend and indemnify Camp Pineshore and its owners, agents, officers and employees from and against any and all claims, actions or losses for bodily injury, property damage, wrongful death, loss of services or otherwise which may arise as a result of the providing of transportation services to my child in conjunction with camp activities including without limitation transportation to, from or during any camp activity. I specifically understand that I am releasing, discharging and waiving any claim or actions that I may have presently or in the future for the acts or other conduct by the owners, agents, officers or employees of Camp Pineshore. I HAVE READ THE ABOVE ‘WAIVER AND RELEASE’ AND BY SIGNING IT AGREE IT IS MY
INTENTION TO EXONERATE AND RELIEVE CAMP PINESHORE FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH CAUSED BY NEGLIGENCE OR ANY OTHER ACT OR OMISSION.
Signature of Self (Or Parent/Guardian if under 18)*

Clear
Name of self (Or parent/Guardian if under 18)*
Date*

MonthDayYear
Date

Authorization for Health Care (If Staff is under 18)
This health history is correct and accurately. The person described has permission to participate in all camp activities except as noted by me and/or an examining physician. If the staff is guardian, I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injections, anesthesia, or surgery for this child. I understand the information on this form will be shared on a “need to know” basis with the camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status.
Signature of Self (Or Parent/Guardian if Under 18)

Clear
Name of self (Or parent/Guardian if under 18)*
Date of Signature

MonthDayYear
Date
Relationship to Staff Member
Should be Empty:

Health Form 2025

Parent/Guardian(s) Info (If under 18)

Emergency Contact

2nd Emergency Contact

Allergies

Diet/Nutrition

Restrictions or Activities

Medical Insurance Info

Medication(s)

Additional Information on Medications

Allergy and Asthma Information

Inhaler Use

General Physical History

Mental and Emotional Health Information

Physician Contacts

Anything we have forgotten to ask?

Staff Physical

Immunization Records

Permission and Waiver

TransportationWaiver and Release of Liability

Authorization for Health Care (If Staff is under 18)