Camp Fusion Staff Health History Form

Camp Fusion Counselor Health History Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age
MaleFemale
Phone Number

Area CodePhone Number
Email
example@example.com
Emergency Contact Name/Relationship*
Emergency Contact Address/Phone Number*
Date of Last Tetanus Booster:*

MonthDayYear
Date
YesNo
YesNo
Please upload an image of your COVID-19 vaccination verification.

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Cancelof
If not, are you scheduled to receive your COVID-19 vaccine prior to camp? (If Yes, please include date scheduled)*
YesNo
If yes, please list the name and required treatment for your bleeding disorder.

Please list all needed medications, including over the counter (OTC)

Upload a copy of your medical insurance card OR fax to 502-210-4232

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Cancelof
Significant Medical History (surgery, serious injuries, hospitalizations)-Explain or NA
Allergies (medication, foods, and contact items like insect bites)-Explain or NA
Special dietary restrictions-Explain or NA
Physical restrictions or limitations to activity-Explain or NA
Primary Care Provider (PCP) or Hemophilia Treatment Center (HTC)
PCP or HTC Telephone Number
PLEASE REMEMBER:
1. Remember to bring enough factor and/or medications for the duration of camp.
2. Check email for CrimCheck background check request and submit information if not done already.

MEDICAL RELEASE (Must be completed and submitted prior to arrival at camp)

In case of accident or illness, medical services may be provided by camp medical/nursing staff. In the event of an emergency and you are unable to give consent for care, the medical center staff is authorized to carry out any procedures deemed necessary. Staff members and volunteers assume financial responsibility for all medical expenses incurred while at camp. Medical insurance information is required in the event a referral of an injured or ill staff /volunteer becomes necessary.

I have read, understand and agree by the above. I attest that I am physically fit for camp and there are no restrictions that would prevent me from performing the essential functions of my role. I understand that Camp Fusion or Bleeding Disorders of KY assumes no responsibility for any pre-existing injury or illness.
Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date

Camp Fusion Counselor Health History Form