Staff Health Form 2025

2025 Med-o-lark Team: Health & Emergency Form

Thanks for helping us create a safe camp experience. Your health history helps our medical team deliver the best care.
Name*

First NameLast Name
Your Email
example@example.com
Emergency Contact *

First NameLast Name
Emergency Contact Number. Please include the country code. *

Country CodeArea CodePhone Number
Emergency Contact Number. Please include the country code. *
Emergency Contact Email*
example@example.com
Emergency Contact Relationship to You
Are you allergic to any medication?*

YesNo
I am allergic to these medication(s):
Do you have any other allergies?

YesNo
Please describe what happens if you are exposed to this/these allergen(s) and how a reaction is managed.
Part 1: Dietary Restrictions

At Camp Med-o-lark, staff set an example for campers by eating the meals provided. Our dining hall has gluten-free and vegan options.
Do you have any dietary restrictions?*

No, I have no dietary restrictionsYes, I have a dietary restriction that is medically necessary (e.g. celiac)Yes, I have a dietary restriction for religious or personal reasons (e.g. vegan)
Please indicate you understand that it is your responsibility to manage your dietary needs at camp. If you have any questions about managing dietary restrictions, please email us at info@medolark.com*

I understand
Part 2: Health History
Have you experienced any of these conditions? (select all that apply)*

AsthmaBack pain/injuryFaintingHeadaches/MigrainesDifficulty breathingSurgical historyJoint weaknessSleep problemsSeizuresNoneOther
What was the date of your most recent tetanus immunization? Please write it as MM/YYYY (e.g. 10/2024).*
Which medication(s) will you be bringing to camp? If none, indicate 'none.'*
Please indicate you understand it is your responsibility to manage your own medication while at camp. Your medication must be kept in the Health Center at all times, except for emergency medications such as epipens and emergency inhalers.*

I understand
Do you have any medical conditions, physical limitations, or chronic health conditions that could limit your ability to perform your job? If so, please describe.
Part 3: Authorization & Agreement

I understand and acknowledge the following:
- My health information will be shared only on a need-to-know basis with camp health staff and my work supervisors.
- I am responsible for managing my own medications at camp.
- I understand that in an emergency, camp will call for medical assistance, and I am responsible for any associated costs.
- I agree to inform camp of any changes to my health before arrival.
- In case of an emergency, we will call the local ambulance service. It takes approximately 15 minutes for an ambulance to arrive.
- Our camp has 2 AED machines and a portable oxygen tank on premises.
- An urgent care center called Sheepscot Valley Medical is available in town. The center is located 9 miles or a 25 minute drive from camp.
I understand and acknolwedge the following about paying for healthcare;
- There is usually no charge for healthcare provided by the camp’s Health Center staff.
- I am financially responsible for healthcare provided by all other providers outside of camp.
- I will bring my bring my insurance card to camp.
Please sign to acknowledge the above.*

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Date

MonthDayYear
Date
Part 4: Essential Job Functions

I am capable of performing the essential functions of my job and participating in assigned work duties as noted on this form. I understand my health information will be used by the camp’s Health Center staff in providing care to me and may be reviewed by my work supervisor(s). I understand that if I have any medication that impairs my ability to perform the essential forms of my job, that I will discuss this with a healthcare provider.
Please sign to acknowledge the above.*

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Part 5: Permission to Treat

I give permission to treat in case of an emergency.
Please sign to acknowledge the above.*

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2025 Med-o-lark Team: Health & Emergency Form

Part 1: Dietary Restrictions

Part 2: Health History

Part 3: Authorization & Agreement

Part 4: Essential Job Functions

Part 5: Permission to Treat