Camp "I AM" Worker Medical Release URLThis field is for validation purposes and should be left unchanged.Name: First Last Gender: Male Female Date of Birth: Address: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact Name(s): First Last Emergency Contact Phone Number:Health HistoryPlace a check beside each appropriate item and give approximate dates if possible:General: Bleed / Clotting Disorders Convulsions Diabetes Frequent Ear Infections Hay Fever Heart Defect / Disease Sleep Walking Operations or Serious Injury Date of Last Tetanus Shot Bleed / Clotting Disorder Dates:Convulsion Dates:Frequent Ear Infections Dates:Diabetes Dates:Hay Fever Dates:Heart Defect / Disease Dates:Sleep Walking Dates:Operations or Serious Injury Dates:Date of Last Tetanus Shot:Known Allergies: Insect Stings Other (List): Penicillin Other Drug Allergies (List): Other known allergies:Other known drug allergies:Diseases: Asthma Chicken Pox German Measles Measles Mumps Date of Asthma Diagnosis: Add RemoveDate of Chicken Pox Illness: Add RemoveDate of German Measles Illness: Add RemoveDate of Measles Illness: Add RemoveDate of Mumps Illness: Add RemoveDo you know of any health factor that makes it advisable for you to follow a limited program of physical activity? Yes No If yes, please explain:Name of your Regular Physician:Physician's Phone Number:Insurance Information(Insurance information is REQUIRED!)Insurance Company Name:Policy Number:Insurance Company Address: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance Company Phone Number:Medication Administration AuthorizationIn the event of a minor illness (i.e. a cold or headache), we have common remedies such as Tylenol, cough medicine, etc. For the safety of the campers, NO medications should be in cabins! Please list any medications that you will be leaving with the Camp Nurse on the Medication Administration Authorization Form!Worker's Name: First Last Medication ListMedicationDose GivenFrequencyAM/PM Add RemoveNOTE: The following are recommended procedures for ADULT WORKER medications: *Although all should be stored with the NURSE (away from campers in the cabins), the adult worker is responsible for the administration of his/her own medications. *Medication must be labeled so that it is not mixed up with a camper's or CIT's meds. *Over-the-counter medication is available for all workers (as specified on the manufacturer's label unless written instructions are provided by the physician). *Unused medication needs to be retrieved at the end of the week (once campers are gone).[We realize that occasionally you may need to leave campgrounds briefly; however, we will need to know prior to your leaving. Please note: We will not allow campers to leave the grounds with anyone under the age of 18 nor without consent of a parent/guardian!]By signing this form, I acknowledge that Camp "I AM" is an extension of the Ogeechee River Baptist Network and will to the best of my ability set a Christ-like example at all times!Also, by signing this form, I am agreeing to work as needed to the best of my ability in all activities, which may include cabin leader, group leader, session leader, or helper with cleaning, set-up, etc. I understand that any items I bring to camp (e.g., cell phones, cameras, athletic equipment, expensive clothing) are my own responsibility, and the camp is in no way responsible for lost/stolen items.I hereby give my consent to medical and surgical treatment as may be needed in the judgment of the treating physician chosen by the Camp "I AM" administration. I understand that twenty-four hour first aid care is available. I further understand that limited secondary accident and illness coverage is provided.SignatureYour NameYour NameYour NameYour Name
