1999 health form

Holston Conference Camp and Retreat Ministries Staff Name (Print)
In an emergency situation, use these contacts as necessary:
Second Parent/Guardian:
Pre-Authorization Phone # if required ( ) Authorization – Must be signed.

In signing this authorization, I acknowledge that I have read the event description and am aware that the activities associated with this event
entail certain inherent risks including damage to property, personal injury, and even death. In consideration for being permitted to participate
in this event, I agree to assume all such risks and hereby release and discharge Holston Conference Camp and Retreat Ministries, Inc., it’s
affiliated camps, officers, sponsors, trustees, employees, agents and other aids and/or volunteers from any and all liability for any and all
damage, loss, injury, or death of every kind and nature whatsoever which in any way arises out of my participation in this event.
I hereby give permission to the camp to provide routine health care, administer prescription drugs, and seek emergency medical treatment including ordering X-rays and/or routine tests. 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, and to order injection and/or anesthesia and/or surgery for me/or my child as named above. The health history on pages 2 and 3 is correct so far as I know. The person herein described has permission to engage in all prescribed camp activities except as noted.
I give permission for me/my child to be transported in a private vehicle if necessary.
I give permission for photographs taken of me/or my child to be used for camp publicity, printed or electronic.
Signature of parent/guardian or adult staff
This form may be photocopied for use out of camp.
Staff Name
General Health Status Yes
Had any recent injury, illness or infectious disease? Ever had problems with ankle or knee joints? Have a chronic or recurring illness/condition? Have any skin problems (itching, rash, etc)? Have asthma? Does camper carry an inhaler? Had problems with diarrhea/constipation? Wear Glasses, contacts or protective eye wear? Ever had chest pains during or after exercise? Ever had emotional difficulties requiring prof. help? Ever been diagnosed with a heart murmur? List other Physical, Emotional, Behavioral, or Mental Health Concerns Has staff ever had an allergic reaction to: (describe what sets off reaction and its severity)
Foods: (Please list)

Immunization Record (complete or attach a copy of Vaccine Administration Records)

Which of the fol owing
Please give all dates of immunization for:
Staff Profile

Parent/Guardian or Adult Staff Signature
Staff Name (Print)
All medications brought to camp, both prescription and non-prescription, must be in the original
containers and clearly labeled with staff’s name. All prescription medications will be dispensed

according to physician’s instructions.

Prescription and Routine Medications – Please list all medications brought by staff to be taken regularly throughout the
camp week listing exact dosage and dispensing orders prescribed by your doctor. Medications must be in original containers. Taken (Breakfast, Lunch, Supper, Bed, Other) Parent/Guardian or Adult Staff Signature verifying instructions: If dispensing orders differ from original container’s label, a Physician’s signature is required: Over-The-Counter Medications - By checking the appropriate box, I give permission for me/my child to receive the fol owing
over-the-counter medications according to the specific directions on the product label unless otherwise directed by a physician. Symptom Medication Headache, Fever Insect Bite Relief (Sting Kill) ointment No oral medications will be given without specific parental authorization.
List any over-the-counter oral or topical medications which you/your child should not receive.

Parent/Guardian or Adult Staff Signature

Source: http://holston.org/media/ministry/resource/STAFF_HEALTH_FORM_2011.pdf

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