Baptist Youth Camp Staff Health Form
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Biological sex
Female
Male
Address
Street Address
Street Address Line 2
City
State
Zip Code
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
If under 18 - parent or guardian Name
First Name
Last Name
Parent/Guardian Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Dietary Allergies
*
Please Select
Yes
No
Please explain Dietary Allergies
Medication Allergies
*
Please Select
Yes
No
Please explain Medication Allergies
Anaphylactic Allergic Reaction?
*
Please Select
Yes
No
Please explain Anaphylactic Reaction
Anything else the staff should know?
List medications and times given. Please bring your medications with their original containers.
By typing my name below I give permission to be treated; I consent to medical attention by the BYC staff and should it be necessary other health care providers.
*
By typing my name below I give permission to be photographed and my image to be used in camp promotional materials.
*
Today's Date
Submit
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