Staff Medical Form

*Denotes Required Field

General Information

* Full Name (First, Initial, Last)

* Date of Birth

* Personal Health Number

* Sex (as stated on birth certificate). Please contact us or note in the comments if you have concerns regarding gender-related needs. We will continue to work to be as accommodating to each situation as possible, as allowed by the limits to our physical building spaces. In all circumstances, the comfort and privacy of all individuals will take priority.

* Doctor's Name

Doctor's Phone Number ( ) -

Medical Questionnaire

This health history is correct as far as I know. Illegal drugs, weapons, and similar items are not permitted at camp. Rough Acres Bible Camp reserves the right to search for and remove such items from anyone suspected of possessing them.

Do you have:

Asthma

Diabetes

Seizures

If so, how severe, what is the treatment protocol/ action plan?

Are you allergic to:

Penicillin

Sulfa

Aspirin

Please State Reaction

Any food allergies? Please state to what/ any reactions.

Any other allergies not mentioned above? Please list reactions.

Able to pursue all camp related physical activities?

If no, please explain

Please list all medications (Medication/Reason for taking it/Dose/Time to be taken)

Any other health concerns?

Emergency Contacts

* Name (1)

* Relationship to Applicant

* Phone ( ) -

* Name (2)

* Relationship (2)

* Phone (2) ( ) -

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