Camp Bethel 2023 Minor Staff Health & Information Form
Your parent or legal guardian must complete and submit this form with you.  

Information from this form will be held confidential by the Health Coordinator and Camp Directors. The intent of this form is to provide the Directors with information needed to provide appropriate emergency care. Provide changes to this form to the Health Coordinator as needed.  If you have insurance, you must email a scan or image of the front & back of your family/child medical insurance card to CampBethelOffice@gmail.com. In any emergency, illness or injury, we will immediately contact the parent/guardian.

The form works best on a laptop or desktop, but if you must use a mobile device, PLEASE use correct spelling and capitalization, and be careful with tricky pull-down menus.

SCROLL THIS FORM DOWN AS YOU GO, and be sure to click the SUBMIT button at the bottom of the form!  Items with a red * asterisk are REQUIRED items.
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Staff's FIRST name *
Thank you for using correct capitalization for names and titles throughout this health form.
Staff's LAST name *
Thank you for using correct capitalization for names and titles throughout this health form.
Staff's Date of Birth *
REQUIRED QUESTION:  M/D/YYYY; example: 3/9/2014  or  12/18/2006.
MM
/
DD
/
YYYY
Permanent Address (where we will mail your W2s) *
Thank you for using correct capitalization for street name
City *
Thank you for using correct capitalization for city
State *
Thank you for using correct capitalization and state abbreviation
Zip Code *
Staff Cell Phone Number *
include area code, (ex: 540-555-1234)
Staff Home Phone Number (if applicable)
Staff Email Address *
Parent/Guardian's First & Last Name *
Main phone of Parent/Guardian *
include area code, (ex: 540-555-1234)
Emergency Contact Information
If we need to give important information to parents, but we cannot reach parents, who should we contact?
Who should we call first if Parent/Guardian is not available? *
Please Give First & Last Name
Their main phone *
include area code, (ex: 540-555-1234)
Who should we call second if Parent/Guardian is not available? *
Please Give First & Last Name
Their main phone *
include area code, (ex: 540-555-1234)
INSURANCE INFORMATION
If you have insurance, you must email a scan or image of the front & back of your medical insurance card to CampBethelOffice@gmail.com.
Is this person covered by family medical/hospital insurance? *
Is this person covered by Medicaid? *
Name of Primary Care Physician *
Please Give First & Last Name
Phone Number of Primary Care Physician *
include area code, (ex: 540-555-1234)
Hospital Affiliation *
ALLERGIES & RESTRICTIONS
List all known allergies and restrictions.  Describe the severity of each including your child's reaction and the best management of the reaction. Describe the best accommodation, adaptations, or limitations of any restrictions. If none, write NONE.
Food allergies *
Medication allergies *
Other or environmental allergies *
Dietary restrictions *
Restrictions or exemptions to camp activities *
What cannot be done; what adaptations, accommodations or limitations are necessary?
Other restrictions or health concerns? *
MEDICAL HISTORY: *
Describe any past or current injury, illness, disease, treatment, surgery, or affliction the camp should know in case of emergency.
ADDITIONAL INFORMATION: *
Describe other physical, emotional, or behavioral concerns or any conditions requiring medication, treatment, or special restrictions or considerations while at camp.
PERMISSION TO ADMINISTER OVER-THE-COUNTER MEDICATIONS: *
In case of headaches, low grade fever, slight upset stomach, mild diarrhea, mild allergic reactions, aches and pains, or cold symptoms, the Camp Bethel Health Coordinator has my permission to administer the following over-the-counter medications (or their generic): Benadryl, Cold/Cough Medicine, Ibuprofen, Imodium AD, Pepto Bismol, Sudafed, Tums Antacid, and Tylenol.
Exceptions to over-the-counter medications above
If you answered "Yes, but with my listed exceptions...", please list those over-the-counter medications listed above that you do NOT grant us permission to administer.
MEDICATION THAT WILL BE NECESSARY DURING CAMP EMPLOYMENT:
If staff member will require medication during employment(either prescribed, over-the-counter, as needed, etc), you must indicate "YES" below AND complete and return a paper copy of the "Camp Bethel Medication Instructions" form (page 3 of 3) at: https://www.campbethelvirginia.org/uploads/1/1/0/2/11021295/minorhealthform2021.pdf

List ALL medications (including non-prescription drugs) on the Medication Form.  Bring enough medication to last the entire time at camp.  Keep it in the original packaging naming prescribing physician, name of medication, dosage, and frequency of administration.  If, during your employment at Camp Bethel, you will be taking medication that might impair your ability to perform essential functions described in your position description, call today to speak with the Camp Director or Health Coordinator.
Will this person need medication on a routine basis?
Clear selection
IMMUNIZATION HISTORY -OR- WAIVER:
Families who voluntarily exempt their children from select school-required immunizations OR who voluntarily exempt themselves from providing proof of immunization must sign the waiver (#2) below if you do not check YES below.
Do you attest that all immunizations required for school attendance are up to date for this staff member? *
If you choose not to answer, you must sign the waiver in #2 below.
1. Tetanus Immunization month and year:
Due to the nature of camp, tetanus immunization is strongly recommended and may be helpful in case of emergency.  Write month and year of the most recent tetanus immunization for this staff member.  DTP (diptheria/tetanus/pertussis), or TD (tetanus/diptheria), or Tetanus.  If you choose not to answer, you must sign the waiver in #2 below.
2. IMMUNIZATION WAIVER: If you chose not check YES above and/or to provide information in (1) above, please sign and date below by writing your name.
NAME AND DATE: Please sign the following statement:  “I understand and accept the potential risks to one who is not fully immunized.”
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