Tall Pines Day Camp | Staff Health Form

Staff Health Form

Complete the form below. Be sure to verify all information is accurate before clicking submit.

This form to be filled in by parents/guardian of minors or by adult campers/staff members themselves.

NO DOCTOR SIGNATURE REQUIRED

First Name*

Last Name*

Birth Date*

Sex

Male
Female

Age

Emergency Contact # 1

First Name*

Last Name*

Relationship

Phone*

Mobile Phone

Emergency Contact # 2

First Name

Last Name

Relationship

Phone

Mobile Phone

Health History

(Check All That Apply)

Frequent Ear Infections
Heart Defect/Disease
Convulsions
Diabetes
Bleeding/Clotting Disorders
Hypertension
Psychiatric Treatment
Mononucleosis
Covid-19 History

Diseases

(Give Approximate Dates)

Chicken Pox

Measles

German Measles

Mumps

Hay Fever

Allergies

(Check All That Apply)

Ivy Poisioning
Insect Stings
Penicillin
Other Drugs
Asthma

Additional Information

Has this person ever required any psychiatric counseling or hospitalization?

Operations or serious injuries (dates):

Disability or chronic or recurring illness:

Any specific activities to be encouraged or limited by physician's advice:

Dietary modifications:

Current Medication (send with instructions):

Other diseases or details of above:

Name of dentist/orthodontist:

Phone Number of dentist/orthodontist:

Name of family physician:

Phone Number of family physician:

Date of last physical examination (mm/dd/yyyy):

Do you carry family medical/hospital insurance? If so, indicate:

Yes
No

Carrier:

Policy or Group #:

Suggestions or health related information for camp personnel:

(For Female): Has this person menstruated?

Yes
No

If not, has she been told about it?

Yes
No

If so, is her menstrual history normal?

Yes
No

Special Consideration:

Immunization History

Please record the date (month and year) of basic and most recent booster dosages:

ALL IMMUNIZATIONS ARE UP TO DATE AS OF THE SIGNATURE DATE (Please check if this applies)

Up To Date

Covid-19 Vaccine Date

Disclaimer

This health history is correct so far as I know, and the person listed above has permission to engage in all prescribed camp activities except as noted. I hereby give permission to the camp: to provide ongoing health care and to select medical personnel and to order X-rays or routine tests or treatment for the person listed above. Emergency Authorization: In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and to order injections and/or anesthesia and/or surgery for the person named above. I also understand and agree to abide with the restrictions placed on my camp activities. This form may be photocopied for use out of camp.

By checking the box you are agreeing to the terms above

I agree

Name of person filling out this form:*

Staff Health Form

Staff Health Form

Emergency Contact # 1

Emergency Contact # 2

Health History

Diseases

Allergies

Additional Information

Immunization History

Disclaimer

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