WCYC Staff health form

To be completed and signed by Applicant (Please print)

                   Date of          

Staff Name_________________________________Birth  ____/____/____  Age___ M____F____

Home Address______________________________________ Work Phones  (___)______________

                     

                   ______________________________________                        (___)______________

                       City                                             State  Zip  

                                                                                                                              

Family Doctor ______________________________________ Doctor's Phone(___)______________

Office Address________________________________________

                      ___________________________ ___ _________

                      City                                                State  Zip

Other Emergency Contact and Telephone Numbers   

Name____________________________Home Phone(___)_____________Work Phone(___)_____________

Wisconsin Christian Youth Camp carries insurance for each Staff member.  In the event you require treatment for a

pre-existing problem or intentional self-inflicted injury, the bill will be sent to you as these are not covered by WCYC.

WCYC requires that ALL medications be surrendered to the camp nurse upon arrival at camp.  The camp nurse will store the medications and dispense them according to Physician's directions on original labeled containers given to the nurse.

All tick bites while at camp must be brought to the nurse so diagnosis can be made for possible Lymes infection.

Date of last Tetanus Booster___/___/___ Known Allergies & Reactions________________________

Have you been exposed to any communicable disease (strep, measles, etc. in past three weeks)?

List medications, dosages, conditions and serious injuries or operations and whether or not  follow up will be necessary while at camp.  Please provide a photocopy of your insurance card.

________________________________________________________________________________

Are you willing to take over-the-counter preparations at the nurse's discretion?  Yes___   No___

Other information that will be helpful to the camp nurse while you are at camp.__________________

________________________________________________________________________________

I hereby authorize Wisconsin Christian Youth Camp to seek medical treatment, shots,

or X-Rays for me (name) ___________________________in an emergency situation.

WCYC has this authorization (dates while attending camp) from____/____/____to____/____/____.

Signature ______________________________________________  DATE ____/____/____