Braeside Camp...where summertime dreams make lifetime memories.

640 East Main Street BRAESIDE Bee’s

Middletown, NY 10940 Bee Responsible…Bee Respectful…Bee Kind

Phone/fax 845-343-8985

CAMP STAFF

HEALTH HISTORY AND MEDICALEXAMINATION FORM

Health History to be completed by staff member

Name:______Date of Birth: ____ / ____ / ____Age:______

Permanent address: ______City: ______State: ______Zip: ______

Phone:______Cell:______

Email:______

Emergency Contact: ______Phone: ______

Address:______City: ______State: ______Zip: ______

Emergency Contact: ______Phone: ______

Address: ______City: ______State: ______Zip: ______

Health History (Check & write approximate dates)

History & Recurring Illnesses / Diseases: / Allergies:
_____ Frequent Ear Infections / _____ Hepatitis / _____ Chicken Pox / _____ Hay Fever
_____ Heart Defect/Disease / _____ Psychiatric Treatment / _____ Measles / _____ Poison Ivy
_____ Convulsions / _____ Mononucleosis / _____ German Measles / _____ Insect Stings
_____ Diabetes / _____ Asthma / _____ Mumps / _____ Penicillin
_____ Hypertension / _____ Other / _____ Other / _____ Other Drugs
_____ Bleeding/Clotting Disorders / _____ Food Allergies
_____ Other

Haveyou ever had any:

Psychiatric counseling or hospitalization? Yes NoDates: ______

Operations or serious injuries? Yes NoDates: ______

Disability or chronic/recurring illnesses Yes NoDates: ______

Details of above: ______

Dietary Restrictions (please circle all that apply)

Vegetarian Does not eat red meat Does not eat chicken Does not eat dairy Lactose intolerant

Dietary modifications: ______

Current medication): ______

Do you carry medical/hospital insurance: Yes No If yes, Insurance Co. name: ______

Policy or Group #:______Phone: ______

PLEASE ATTACH A COPY OF THE FRONT AND BACK OF YOUR MEDICAL INSURANCE CARD

Emergency Authorization in the event the staff member cannot communicate

I hereby give permission to the medical personnel selected by Braeside Campto order x-rays, routine tests and treatment for myself, and in the event I cannot communicate, I hereby give permission to the physician selected by Braeside Camp to hospitalize, secure proper treatment for and to order injection and /or anesthesia and/or surgery for myself as named above. This form may be photocopied for use off of property. I also give permission for routine medical care for myself by Braeside Camp.

CampStaff Member Signature: ______Date:______

Immunization History (must be completed for employment)

Vaccines / Year of basic immunization / Year of last booster
Diphtheria
Pertussis(Whooping Cough) }(DPT)
DPT Tetanus or / 1.
2.
3. / 1.
2.
Tetanus
Diphtheria } Booster TD or
Tetanus
Oral Polio (Sabin) (TOPV)
Inject able Polio (Salk)
Measles
Mumps
Rubella (German Measles, 3-day measles)
Tuberculin Test given ______/ Result:
Meningococcal Meningitis
Hepatitis B
Other:

Health Exam to be conducted and completed by Licensed Physician:

I have examined above applicant within the past two years. Date Examined: ______

The applicant is under the care of a physician for the following condition(s): ______

______

In my opinion the above condition does ____ does not ____ preclude his/her participation in an active program.

Current treatment (included current medications):______

______

Explanation of any reported loss of consciousness, convulsions or concussion:______

Recommendations and Restrictions:

Any treatments to be continued: ______

Any medication to be administered (specific doses):______

Any medically prescribed meal plan or dietary restrictions: ______

Any allergies (food,drugs, plants & insects, etc.)______

Additional Health Information: ______

______

Licensed Physician’s Signature:______Phone: ______

Address: ______Fax: ______

Date of form completion: ______