Staff Health Form 2026

  • Health Form 2025

    For Staff at Camp Pineshore Bible Camp. Staff under 18 will need parent/guardian signature.
  • Date of Birth*
     - -
  • Gender*

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

    With Legal Custody To Be Contacted First In Case of Illness or Injury
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Emergency Contact

    To be contacted in case of emergency
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • 2nd Emergency Contact

    In Event Parent(s)/Guardian(s) Can't Be Reached
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Allergies

  • Are you allergic to any medications?*
  • Does this cause anaphylaxis?*
  • Do you have any food allergies?*
  • Does this cause anaphylaxis?*
  • Do you have any environmental allergies (bee stings, hay fever, etc.)*
  • Does this cause anaphylaxis?*
  • Do you have a written allergy response plan?*

  • Diet/Nutrition

  • Check all those that apply*

  • Restrictions or Activities

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

  • Medical Insurance Info

  • Are you covered by family medical/hospital insurance?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • 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*

  • 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.

  • General Physical History

    Please answer all the questions below for your camper with yes and no. For any yes answers, please give more detail in the space provided.
  • Has you ever been hospitalized?*
  • Has you ever had surgery?*
  • Do you have a recurrent/chronic illness?*
  • Have you ever passed out/had chest pain during or after exercise or physical exertion?*
  • Have you had a recent infectious disease?*
  • Have you had a recent injury?*
  • Do you have asthma or frequent shortness of breath?*
  • Do you have diabetes?*
  • Do you have frequent headaches?*
  • Do you suffer episodes of fainting of dizziness?*
  • Do your have any skin problems? (for example itching, rashes, or severe acne)*
  • Do you have or ever had a seizure?*
  • Have you ever sprained, strained, dislocated, broken a bone, or had repeated swelling or other injuries?*
  • Have you ever had mononucleosis (mono) in the past 12 months?*
  • Do you have any problems with periods/menstruation?*
  • Do you have any problems with falling asleep or sleepwalking?*
  • Do you ever have any back of joint problems?*
  • Does your camper have a history of bed-wetting?*
  • Does your camper have any problems with diarrhea or constipation?*
  • Does your camper wear glasses or use protective eye ware?*
  • Does your camper have any dental problems?*
  • Have you traveled outside the country in the past nine months?*
  • Have you ever been diagnosed with Covid-19?*

  • 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)?*
  • Has you ever been treated for emotional or behavioral difficulties or an eating disorder?*
  • During the past year, have you seen a professional about any mental or emotional health concerns?*
  • 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.)*

  • Physician Contacts

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Anything we have forgotten to ask?

  • Staff Physical

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • 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. 

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • 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. 

  • Date*
     - -

  • 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.

  • 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.

  • Date of Signature
     - -
  • Should be Empty: