Adult Volunteer and Counselor-in-Training Emergency and Medical Information

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 *

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 *

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

Select this box if you have NO healthcare coverage.

None

Primary Doctor's Name

Doctor/Clinic Phone #

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.

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.

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).

DIET and NUTRITION

I eat a regular diet.
I eat a vegetarian diet.
I have special food needs.

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.

WHAT HAVE WE FORGOTTEN TO ASK?