• Camp Fusion Counselor Health History Form

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender
  •  -
  • Date of Last Tetanus Booster:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are your Immunizations up to date?*
  • Are you a counselor with Hemophilia or a Bleeding Disorder?*
  • Please list all needed medications, including over the counter (OTC)
    Rows
  • Browse Files
    Cancelof

  • 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.

     

  • Image field 13

  • 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.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Image field 15

  • Tuberculosis (TB) Risk Factor Screening

    Universal tuberculin testing is not recommended in the US and other low-incidence countries due to the high rate of false positive results. Tuberculin testing is, however, indicated for children/individuals with risk factors for TB. Please answer the following questions.

  • 1. Have you had an unexplained fever, poor appetite, persistent cough, night seats, fatigue, spitting up blood, or unexplained weight loss in the past year?*
  • 2. Are you an immigrant from OR have traveled to a country (within the last year) with a high incidence of TB? (Caribbean, Latin America, Africa, and Asia, excluding Japan).*
  • 3. Have you had household contact with an individual who immigrated from a country with a high incidence of TB (Caribbean, Latin America, Africa, and Asia, excluding Japan) or an individual who has TB?*
  • 4. Have you had exposure to individuals in the past year who are HIV-infected, homeless, institutionalized, users of illicit drugs, or incarcerated?*
  • Do you have HIV infection, chronic renal failure, malnutrition, reticuloendothelial diseases, other immunodeficiencies, or receiving immunosuppressive therapy?*
  • I have previously tested positive on a TB skin test.*

  • If you answered YES to any of the questions above, please upload documentation of a TB skin test (Mantoux) with your medical form.  If the TB skin test is positive, you will need to submit evidence of a chest x-ray report.

    If you answered NO to all of the above questions, please sign below:

     

    I have none of the identified risk factors:

  • Should be Empty: