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Camp Luther Staff Health Form 2008 |
Please complete and mail to director with application by March 1, 2008. Make a copy for your records.
Name____________________________________________________________________________________
Last First MI
Birth date_____________________ Position at camp_______________________________________
Program: Junior_______ Intermediate_______ Senior__________
Do you wear: eye glasses________ contact lenses_____________
Have you had any surgery or serious illness within the past year? If so, please explain.
Check any that apply to you that the Nursing Staff should know.
_____Allergies:________________________Describe Reaction:_____________________________________
______________________________________________________________________________________________Allergies to drugs and their names:__________________________________________________________
Describe
Reaction:___________________________________________________________________________
__________________________________________________________________________________________
Medications for any of the above:_______________________________________________________________
__________________________________________________________________________________________
____Diabetes________________Medication______________________________________________________
____Heart Condition__________Medication______________________________________________________
____Epilepsy/Convulsions_____ Medication______________________________________________________
____Emotional Problems______ Medication______________________________________________________
____Ear Problems___________ Medication______________________________________________________
____Asthma _______________ Medication______________________________________________________
____Fainting Spells__________ Medication______________________________________________________
____Hay Fever______________ Medication______________________________________________________
Date of most recent tetanus immunization? _____________________
Any other condition (physical or emotional) of which the Nursing Staff should be aware?_______________________________________________
Any medications that you are currently taking other than those listed above?
EMERGENCY INFORMATION
Doctor’s name_____________________________________________ Phone____________________________
Address____________________________________________________________________________
City____________________________ State__________________ Zip________________
Name of person to contact in case of an emergency
Name_____________________________________________________________________
Phone (Home)________________________________Work__________________________________
Thank you for your service to Camp Luther!
Return by March 1, 2008 with your application to: Camp Luther
% Pat Schillings, Director
1600 Kanawha Blvd E.
Charleston, WV 25311