2026 Staff Health History

Name

First NameLast Name

Birthdate

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Email

Are you vegan?

Are you gluten free?

Do you have any food allergies?

If you answered Yes, please list your food allergies here. Please also include whether these allergies affect you by CONTACT (Any part of your body coming in contact with this allergen) or by CONSUMTION (Allergen only effects you if you eat it)

Restrictions or adaptations:

General Health: (check "Yes" or "No" for each statement)

Rows	Yes	No
Do you have a recurrent/chronic illnesses?
Have you had a recent injury?
Do you have asthma/wheezing/shortness of breath
Do you have diabetes?
Have you had seizures?
Do you have migraines?
Do you have problems with fainting or dizziness?
Have you ever passed out/had chest pain during exercise?
Have you ever had back/joint problems?
Have you had debilitating panic/anxiety attacks?

'Medication' is any substance a person takes to maintain and/or improve their health. This includes prescriptions, over-the-counter medications, vitamins and natural remedies.

The following non-prescription medications are stocked in the Camp First-Aid Center and are used on an 'as needed' basis to manage illness and injury. **Please select any that are NOT ALLOWED to be administered to you**

Do you have any (non-food) allergies?

If yes, what allergies do you have?

Emergency Contacts

Rows	Name	Relationship	Phone Number	Email
Contact #1
Contact #2

Are you covered by health insurance

Insurance Company

Insurance Company Phone Number

Policy Number

Subscriber

Is there anything we forgot to ask that may affect your health or the ability to fully participate in the camp program?

Permission to Treat Authorization

I hereby give permission to the medical personnel selected by this Camp's director to provide routine health care; to administer prescribed medications; and to administer emergency treatment for me/my child, including, but not limited to X-rays, routine tests and treatment and/or hospitalization; and to provide or arrange necessary related transportation for me/my child. I also agree to the release of any records necessary for treatment, referral, billing or insurance purposes. If the person named herin is a minor, it is my intention that representatives of the camp be considered "personal representatives" for the purpose of disclosing health information that is protected under the Health Insurance Portability and Accountability Act of 1996. I also agree to the disclosure to camp representatives of protected health information of the person named herein in order to provide information related to the person's ability to participate in camp activities; and if the person named herein is a minor, to provide information to the camp representatives to keep me informed of my child's health situation. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment, inclulding hospitalization, for the named person. This completed form may be photocopied for trips out of camp.

I understand and agree with the Permission to Treat Authorization statement.

Due to our new campground licensing, we are required to ask: Have you ever been convicted of a sexual crime?

All the information I have provided is accurate and true to the best of my knowledge. If anything changes, I will inform the Camp office.

Staff Signature

Parent/Guardian Signature (Required if under the age of 18)

What size T-shirt/Sweatshirt do you wear?

Staff Health History

Dietary

Physical Restrictions

Medications