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Search for:
Home
Congregations
Events
Calendar
2023 Women’s Retreat
2023 Summer Camps
Ministries
Regional Minister Search timeline
Regional Minister Job Posting
Commission on Ministry
Clergy Standing Renewal Form
Clergy Standing Transfer Form
In-Care Request Form
Praying for our In-Care Candidates
Lane Salmon and Clergy Scholarship Funds
Global Ministries
Colombia Partnership
Congregational resources – Columbia
Support our mission coworkers
New Church Ministries
Regional Board
Financial Reporting
Transformation Ministries
Youth and Children’s Ministries
Outdoor Ministries
Summer Camps
Adult Volunteer Application
Adult Volunteer Reference Form
Adult Volunteer Application & Reference Forms – Printable
Adult Volunteer Emergency/Medical Info Form
Resources
For Clergy
Clergy Healthy Boundaries & Anti-Racism/Pro-Reconciliation Training
Clergy Standing Renewal (Hard copy)
Clergy Standing Transfer Form
Lane Salmon and Clergy Scholarship Funds
Job Opportunities
Denomination & Ecumenical Partner Links
Christian Church (Disciples of Christ)
Disciples Home Missions
Disciples Regional Ministries
Disciples Racial-Ethnic Ministries
Disciples Church Extension Fund
Disciples of Christ Historical Society
Hope Partnership Services
The Center for Faith and Giving
Green Chalice
Global Ministries
National Benevolent Association
Week of Compassion
Pacific NW Conf. United Church of Christ
For Congregations
Grants Policy
Search and Call Committee Resources
Church Treasurer Handbook
DMF Special Day Offerings
Visitors
Staff
Values and Mission
More About the Disciples
Job Opportunities
Donate Here
Northern Lights Annual Fund
Disciples Mission Fund
Donations for Congregations
Global Ministries Mission Coworkers Alex & Xiomara
Lane Salmon/Clergy Scholarship Funds
Newsletter
Submit news for Community Connections
Regional News Opt-in
Home
Congregations
Events
Calendar
2023 Women’s Retreat
2023 Summer Camps
Ministries
Regional Minister Search timeline
Regional Minister Job Posting
Commission on Ministry
Clergy Standing Renewal Form
Clergy Standing Transfer Form
In-Care Request Form
Praying for our In-Care Candidates
Lane Salmon and Clergy Scholarship Funds
Global Ministries
Colombia Partnership
Congregational resources – Columbia
Support our mission coworkers
New Church Ministries
Regional Board
Financial Reporting
Transformation Ministries
Youth and Children’s Ministries
Outdoor Ministries
Summer Camps
Adult Volunteer Application
Adult Volunteer Reference Form
Adult Volunteer Application & Reference Forms – Printable
Adult Volunteer Emergency/Medical Info Form
Resources
For Clergy
Clergy Healthy Boundaries & Anti-Racism/Pro-Reconciliation Training
Clergy Standing Renewal (Hard copy)
Clergy Standing Transfer Form
Lane Salmon and Clergy Scholarship Funds
Job Opportunities
Denomination & Ecumenical Partner Links
Christian Church (Disciples of Christ)
Disciples Home Missions
Disciples Regional Ministries
Disciples Racial-Ethnic Ministries
Disciples Church Extension Fund
Disciples of Christ Historical Society
Hope Partnership Services
The Center for Faith and Giving
Green Chalice
Global Ministries
National Benevolent Association
Week of Compassion
Pacific NW Conf. United Church of Christ
For Congregations
Grants Policy
Search and Call Committee Resources
Church Treasurer Handbook
DMF Special Day Offerings
Visitors
Staff
Values and Mission
More About the Disciples
Job Opportunities
Donate Here
Northern Lights Annual Fund
Disciples Mission Fund
Donations for Congregations
Global Ministries Mission Coworkers Alex & Xiomara
Lane Salmon/Clergy Scholarship Funds
Newsletter
Submit news for Community Connections
Regional News Opt-in
Adult Volunteer and Counselor-in-Training Emergency and Medical Information
Adult Volunteer and Counselor-in-Training Emergency and Medical Information
northernlightsdisciples
2022-06-21T22:05:15-07:00
Please enable JavaScript in your browser to complete this form.
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Step
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Camp Volunteer Emergency and Medical Information
THANK YOU for taking the time to complete this Emergency Contact and Medical form. Your information will be provided to the event director (and designated medical staff as necessary) but is otherwise confidential. Remember, this form is renewed for every volunteer opportunity since health concerns and medicine information changes rapidly.
Your Name
*
First
Middle
Last
Your Primary Email Address
*
Next
Emergency Contacts
Primary Contact
For Minors/CITs, the Primary Contact should be Parent or Custodial Adult
Name
*
First
Last
Best Phone Number
*
Relationship to Volunteer
*
Second Contact
Name
*
First
Last
Best Phone Number
*
Relationship to Volunteer
*
Next
Health Insurance
If you/your CIT requires medical treatment while volunteering, your insurance information will be used at the hospital. Please provide that information below. If you select "No Insurance" please type NA in the Carrier and Policy number sections.
Insurance Carrier or Plan Name
Policy Number/Group Number/or other ID #
Birth Date of the Policy Holder
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Select this box if you have NO healthcare coverage.
None
Primary Doctor's Name
Doctor/Clinic Phone #
Next
Medication
"Medication" is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. All medications, including those of volunteers, will be stored securely for the duration of the event.
Please list ALL medications (including over-the-counter or non-prescription drugs) taken routinely. Bring only enough medications to last the entire time at camp. Keep it in the original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration.
Will/Will Not Bring Meds
The volunteer WILL NOT be taking any daily medications during the event.
The volunteer WILL be taking daily medications during the event.
1. Medication Name
1. Dose/Time
2. Medication Name
2. Dose/Time
3. Medication Name
3. Dose/Time
4. Medication Name
4. Dose/Time
More Medicines?
Click or drag a file to this area to upload.
If you have more than four medicines to take, please use this Upload tool to provide a comprehensive list. We prefer the list is typed and saved as a Word, Text, or PDF document. You may also email the list to asaladino@disciplesnw.org
For Minors/Counselor-In-Training
Camp staff HAS PERMISSION to administer over-the-counter medications as necessary.
Minor/CIT SHOULD NOT be given any over-the-counter medications.
Camp staff HAS PERMISSION to administer over-the-counter medications as necessary EXCEPT as noted below.
Exceptions to Over-the-Counter Medications Allowed
Next
Brief Medical History
Answers to these questions will help ensure your needs are planned for and in an emergency appropriate care can be administered.
GENERAL ALLERGIES
No known allergies.
Food allergies.
Medicine allergies (such as penicillin).
Environmental allergies (such as pollen or mildew).
Identify and Describe Allergies
DIET and NUTRITION
I eat a regular diet.
I eat a vegetarian diet.
I have special food needs.
Briefly describe any special food needs.
VACCINATIONS
Measles
German Measles
Mumps
Chicken Pox
Hepatitis A
Hepatitis B
Hepatitis C
Positive TB Mantoux Test
COVID-19 (up to date)
NO vaccinations or booster shots.
Please check all boxes that apply.
SOCIAL and EMOTIONAL HEALTH
Treated for attention deficit disorder or attention deficit/hyperactivity disorder.
Treated for emotional or behavioral difficulties or an eating disorder
Seeing a professional to address mental/emotional health concerns in the last 12 months.
Had a significant life event that continues to affect your life.
Consider yourself to be emotionally and socially stable.
Briefly describe any statements check marked.
GENERAL HEALTH CONCERNS
Has been hospitalized in the last 12 months.
Has had surgery in the last 12 months.
Has recurrent/chronic illness(es).
Had a recent infectious disease.
Had a recent (major) injury.
Had/Has asthma/wheezing/shortness of breath.
Has diabetes.
Had/Has seizures.
Had/Has migraine headaches.
Wears glasses, contacts or protective eyewear.
Has a history of bedwetting.
Has problems with diarrhea/constipation.
Has any skin problems.
Has frequent nose bleeds.
Had/Has back/joint problems in last 12 months.
Has problems with falling asleep/sleepwalking/nightmares.
Had mononucleosis (mono) during the last 12 months.
Had/Has fainting or dizziness in last 12 months.
Has passed out/had chest pain during exercise in last 12 months.
If female, had/has problems with periods/menstruation.
Has traveled outside the country in the past 9 months.
I consider myself in good general health.
WHAT HAVE WE FORGOTTEN TO ASK?
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