Counselor Medical Form

In order that CRC may provide the best health care for the counselors during camp, please list all medications you are currently taking. Even if you do not regularly take any medications, this form still needs to be signed and submited to complete your application process. It is generally our practice to call a parent when a major medical issues arises or one thatrequires more than one visit to the Nurse’s Station (e.g. injuries requiring more than simple first aid, or for headache, sore throat, etc. that does not respond to treatment.)

During camp, all medications must be turned into the Nurse on the first day of camp and must be in the original packaging/container.

Name*

First NameLast Name

Birth Date*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

#1 Parent / Guardian's Name*

First NameLast Name

Parent / Guardian's Phone Number*

Area CodePhone Number

Relationship to #1 Parent / Guardian:*

#2 Parent / Gaurdian's Name*

First NameLast Name

Parent / Guardian's Phone Number*

Area CodePhone Number

Relationship to #2 Parent/ Guardian:*

Are you in general good health & able to participate in all normal camp activities?*

YesNo

Is our camp nurse able to provide you with Advil?*

YesNo

Is our camp nurse able to provide you with Tylenol?*

YesNo

If no, please submit a statement of limitations.*

Prescription Medications: Please list the name of all medication, how often taken, and reason for use.*

Non-Prescription Medications: Please list all vitamins, food supplements, etc. and name of medication, how often taken, and reason for use.*

Do you have dietary needs? Please list the reason for dietary needs.*

Specific Allergies/Treatment Given:*

Date of last tetanus shot:*

Preexisting Medical Condition:*

Primary Care Physician and Phone Number:*

Insurance Company and Policy Number:*

Release Statement:

The undersigned does hereby release, discharge, indemnify, and hold harmless Christian Retreat Center and The Allegheny and Susquehanna Conferences of the Brethren in Christ Church and all of their parent and affiliated organizations and all of their officers, agents, contractors, directors, members, participants and employees from all claims, demands, actions, judgments, and/or liabilities of whatsoever kind of nature, including any costs, attorneys’ fees, losses or expenses in connection therewith, in any way relative to, arising out of, or by reason of, my participation in, and attendance at, Christian Retreat Center and/or related facilities, including all claims or demands for death or injury to me, or any damage to, or destruction of any of my property arising out of any accident or occurrence with, said attendance, participation and/or presence, whether negligent or otherwise. This waiver, Release and Indemnification is given in consideration of, and as a condition to, permitting the undersigned to participate at Christian Retreat Center. In signing this form, I hereby certify that all information is correct and I give permission for the use of photographs, audio, and video footage including my child in camp publicly, for my child to be transported in a camp operated vehicles for approved out-of-camp activities and for purpose of medical transport, and for the release of medical records in case of illness.

Please Sign below:*