Tall Pines Day Camp

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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.

Last Name:
First Name:
Birth Date:
Sex:	Male Female
Age:
Parent or Guardian (or spouse):
Last Name:
First Name:
Home Address
Street:
City:
State:
Zip:
Phone:
Cellular Phone:
Second Parent or Guardian (or spouse):
Last Name:
First Name:
Home Address
Street:
City:
State:
Zip:
Phone:
Cellular Phone:
If not available in an emergency, notify:
Last Name:
First Name:
Relationship:
Home Address
Address:
City:
State:
Zip:
Phone:
Cellular Phone:

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:
Name of family physician:	Phone:

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

Do you carry family medical/hospital insurance? Yes No If so, indicate:

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)

Vaccines	Year of Basic Immunizations	Year of Last Booster
Diphtheria }DPT
Pertussis (Whopping Cough) }DPT
Tetanus/diptheria

Tetanus }TD
Diptheria }TD

Tetanus
Oral Polio (Sabin) TOPV
Injectable Polio (Salk)
Measles (hard measles, red measles, Rubeoia)
Mumps
Rubella (German measles, 3-day measles)
Other
HIb/Haemophilis B
Tuberculin test given	(most recent)

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

Name of person filling out this form: