Date Rec’d ________
Copies Made ______
STAFF HEALTH FORM
INSURANCE INFORMATION
NAME: __________________________________________________________ Sex ______ Age ________
HOME ADDRESS: _______________________________________________________________________
CITY: ___________________________________________________ STATE: ______ ZIP: _____________
HOME PHONE: (______)____________________ WORK: (______)___________________
INSURANCE POLICY
Name of Policy Holder: ____________________________________________________________________
Phone Number: ______________________ Policy/Group # _____________________________________
Type of Coverage: _______________________________________________________________________
Please include a copy of your insurance card
Doctor’s Name: ____________________________________________ Phone: (_____)________________
Address: ______________________________________________________________________________
ALLERGIES: (Please check all that applies)
_____ Bee Sting _____Poison Ivy _____Pencillin _____Poison Oak
_____ Sumac _____Dust _____Other (please list and explain) _________________________
______________________________________________________________________________________
______________________________________________________________________________________
Any special dietary requirements and/or restrictions: _____________________________________________
Last date of your Tetnus shot? _________________________
Please list any restrictions or limitations we should know about.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
PLEASE CHECK ALL THAT APPLIES TO YOU
_____ Asthma _____ Diabetic _____Takes cold easily _____ Sunburns easily
Medication or Insulin Dose Directions Total Pills Nurse
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
IN CASE OF AN EMERGENCY NOTIFY:
NAME: _______________________________________________________________________________
PHONE: (______)__________________ OTHER: (______)_____________________________
AUTHORIZATION FOR EMERGENCY MEDICAL CARE
I, _____________________________________ hereby give my permission to camp officials to call a doctor or
emergency medical service and for the doctor, hospital or medical service to provide medical, to order injection,
anesthesia or surgical care should an emergency arise. It is understood that camp officials will make a
conscientious effort to locate the emergency contacts listed above before any action will be taken. If it is not
possible to locate emergency contacts listed, I accept the expense of emergency medical or surgical treatment.
_____________________________________________________ ____________________
Signature Date
8/2008
Copies Made ______
STAFF HEALTH FORM
INSURANCE INFORMATION
NAME: __________________________________________________________ Sex ______ Age ________
HOME ADDRESS: _______________________________________________________________________
CITY: ___________________________________________________ STATE: ______ ZIP: _____________
HOME PHONE: (______)____________________ WORK: (______)___________________
INSURANCE POLICY
Name of Policy Holder: ____________________________________________________________________
Phone Number: ______________________ Policy/Group # _____________________________________
Type of Coverage: _______________________________________________________________________
Please include a copy of your insurance card
Doctor’s Name: ____________________________________________ Phone: (_____)________________
Address: ______________________________________________________________________________
ALLERGIES: (Please check all that applies)
_____ Bee Sting _____Poison Ivy _____Pencillin _____Poison Oak
_____ Sumac _____Dust _____Other (please list and explain) _________________________
______________________________________________________________________________________
______________________________________________________________________________________
Any special dietary requirements and/or restrictions: _____________________________________________
Last date of your Tetnus shot? _________________________
Please list any restrictions or limitations we should know about.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
PLEASE CHECK ALL THAT APPLIES TO YOU
_____ Asthma _____ Diabetic _____Takes cold easily _____ Sunburns easily
Medication or Insulin Dose Directions Total Pills Nurse
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
IN CASE OF AN EMERGENCY NOTIFY:
NAME: _______________________________________________________________________________
PHONE: (______)__________________ OTHER: (______)_____________________________
AUTHORIZATION FOR EMERGENCY MEDICAL CARE
I, _____________________________________ hereby give my permission to camp officials to call a doctor or
emergency medical service and for the doctor, hospital or medical service to provide medical, to order injection,
anesthesia or surgical care should an emergency arise. It is understood that camp officials will make a
conscientious effort to locate the emergency contacts listed above before any action will be taken. If it is not
possible to locate emergency contacts listed, I accept the expense of emergency medical or surgical treatment.
_____________________________________________________ ____________________
Signature Date
8/2008
