Staff Medical Form - Confidential

Sagitawa Christian Camps

mark as N/A if field required but not applicable


BASIC INFORMATION:

Full Name*
Address*
Phone - home*
Phone - alternate

MEDICAL INFORMATION:

In case of serious accident or illness every person must be covered by the BC Health Plan or an equivalent policy.

Health Care #*
Describe Medical Plan if other than provincial in BC*
Family Doctor*
Doctor's phone*
Date of last tetanus shot (mm/yy)*


SPECIAL DIETARY REQUESTS:

Non-Allergy

List non-allergy requests and reasons

Allergy Related

List food allergies, reactions and remedies.
Please be specific.
Is there anything we should know regarding
the need for further medical attention?

ALLERGIES:

List other allergies, reactions and remedies.
Please be specific.
Other details regarding the need for further medical attention?


MEDICATIONS:

Our First Aid department generally stocks basic over-the-counter medications. The list below is only a sample of the more common medications we would normally carry.

  • Antihistamines:  Benadryl, Loratadine
  • Cough and cold:  throat lozenges, cough syrups (no codeine), cold capsules
  • Analgesics:  Acetaminophen, Ibuprofen, (also under brand names ie: Tylenol, Advil)
  • Digestion:  Tums, Pepto Bismal, Gravol
Please list any over-the-counter meds to which
you oppose being given to this individual.
Prescriptions currently being taken.
Please provide need-to-know information.

Any medications you bring must be in the original container. Prescriptions may only be used by the person for whom they are prescribed.


OTHER CONDITIONS:

Recent operations we should know about?
Illnesses/ injuries receiving medical attention in last yr?
Recent contagious contact (i.e.: chicken pox, flu)?
Please describe any health restrictions, mental
health concerns, or educational needs.


WAIVER & SIGNATURE:

If under 19 years... PARENT /GUARDIAN MUST READ and SIGN

I recognize that camp activities involve a degree of spontaneity and risk, and that accidents may occur. I am aware of the types of activities at the camp my child is attending, and I accept the risks of possible injury. Should injury require emergency treatment, which would be delayed by efforts to contact me, I hereby grant permission to the Camp Director or First Aid Attendant to authorize medical treatment and inform me as soon as possible.

 

Print Full Guardian Name
Date of signature
Signature (clicking is intent to sign)