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.



    • Emergency Contact # 1

    • Emergency Contact # 2

    • Health History

      (Check All That Apply)
    • Diseases

      (Give Approximate Dates)
    • Allergies

      (Check All That Apply)
    • Additional Information

    • Immunization History

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