Medical Staff Health Form

Name*

First Last

Are you allergic to any medication?

Yes
No

If so please explain.

Date of last tetanus?

Any chronic illness NOT including diabetes?

Yes
No

If so please explain.

Are you or could you be pregnant?

Yes
No

If so please explain.

Do you have an injury or health concern that would not allow you to perform your duties at camp?

Yes
No

If so please explain.

Do you have diabetes?

Yes
No

If so, type 1 or 2

1
2

Do you take insulin?

Yes
No

skip if you do not have diabetes

if so, what type of insulin?

Do you use a pump/pod?

Yes
No

If so, name of pump?

Select one of the following concerning medications you are currently taking:

I do not take any routine medication
I am attaching a list of medications below
I do not wish to disclose medications I may or may not be taking as they do not interfere with my abilities and are not life saving medications
I am listing my medications below

Upload a list of medications

Max. file size: 32 MB.

List of medications

List or describe any additional medical information that we should know about you

Authorization for medical treatment

I agree to the following

I acknowledge this health history is correct so far as I know and then believe I am able to engage in all camp activities except as noted. In the event I am unable to speak for myself during an emergency, I hereby authorize the physician selected by the camp designated director(s) to hospitalize, secure proper treatment for, and to order and administer : medications, injections, anesthesia, blood and blood products, or surgery for me.