Staff Health Statement Form


Full Name
Birth Date
Camp Position (if known)
Camp Program
Do you wear eyeglasses?
Do you wear contacts?
Have you had any surgery or serious illnesses within the last 6 months?
If so, please explain
Health History
Drug Allergies
If so, please provide details
Other Allergies
If so, please provide details
Date of last tetanus shot (dd/mm/yyyy)
Please list ALL Conditions** and all medications you are taking: (Also list conditions that you have that do not require medication) Examples of Conditions include but are not limited to: High blood pressure, heart problems, diabetes, epilepsy Asthma, Migraines, Emotional Problems, Ear Problems, etc.
Please list Condition, Medication, Dose, and Frequency taken. Use a separate line for each condition.
Emergency Information
Doctor's Name
Address, City, State, Zip
Name of person to contact in case of an emergency
Home Phone
Work Phone
Cell Phone