Camp Bethel 2023 Adult Staff Health & Information Form
To be completed by you, the adult staff member. This 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.

All information will be held confidential by Camp Bethel. This form supplies the Health Coordinator with information needed to provide appropriate emergency care, and this form supplies the Camp Director with vaccination information needed for safely organizing the summer program. Provide changes to this form to the Health Coordinator as needed.

As you have them ready, upload your completed forms and requested information using the Staff Upload Portal at https://www.campbethelvirginia.org/staffresources.html

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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FIRST Name *
Thank you for using correct capitalization for names and titles throughout this health form.
LAST Name *
Thank you for using correct capitalization for names and titles throughout this health form.
Date of Birth *
REQUIRED QUESTION:  month / day / year; M/D/YYYY; example: 3/9/2014  or  12/18/2006.
MM
/
DD
/
YYYY
Permanent Address (where we will mail your W2s) *
This is the mailing address to where we will mail your W2 tax forms in January 2022, (which might not be your current college address, so probably use your parents' address). 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 *
Your Cell Phone Number *
include area code, (ex: 540-555-1234)
Your Home Phone Number (if applicable)
Your Email Address *
The email address you use most frequently.
Emergency Contact Information
Who should we contact in case of an emergency?
Name of First Emergency Contact *
Please Give First & Last Name
Their main phone *
include area code, (ex: 540-555-1234)
Name of Second Emergency Contact *
Please Give First & Last Name
Their main phone *
Include area code, (ex: 540-555-1234)
Are you covered by medical/hospital insurance? *
We request that you upload a scan/image of the front and back of your insurance card. Use the upload portal at https://www.campbethelvirginia.org/staffresources.html
Are you 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 reaction and the best management of the reaction. Describe the best accommodation, adaptations, or limitations of any restrictions. If none, write NONE.
Food allergies *
If none, write NONE.
Medication allergies *
If none, write NONE.
Other or environmental allergies *
If none, write NONE.
Dietary restrictions *
If none, write NONE.
Restrictions or exemptions to camp activities *
What cannot be done; what adaptations, accommodations or limitations are necessary? If none, write NONE.
Other restrictions or health concerns? *
If none, write NONE.
MEDICAL HISTORY: *
Describe any past or current injury, illness, disease, treatment, surgery, or affliction the camp should know in case of emergency. If none, write NONE.
ADDITIONAL INFORMATION: *
Describe other physical, emotional, or behavioral concerns or any conditions requiring medication, treatment, or special restrictions or considerations while at camp. If none, write NONE.
Will you take medication while on site at Camp Bethel?
Our Adult Medication Form is a printable form available at https://www.campbethelvirginia.org/staffresources.html
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