The following is the medical release and health history form required by Lake Lundgren Bible Camp in Pembine, Wisconsin where CYM's Senior High ministry travels each January for a weekend service project:

 
STAFF HEALTH HISTORY
Lake Lundgren Bible Camp

You must complete and bring a current Health History each time you come to serve at camp.


Name:                                                                                                              

       first        initial        last

Birth date:                       Age:             Sex:  ______
 
Address: ___________________________________________________________________________________
                       street                                   city                       state               zip
In case of an emergency, notify: ___________________________________Relationship:   ___________________       
    
Address: ___________________________________________________________________________________
        street            city            state                zip

Work Phone:  (____)______________Home Phone:  (____)______________Cell Phone: (____)_____________
   
Health/Accident Insurance:  ___________________________________________________________________

Insurance Holders Name on Card __________________________ Expiration Date:  ______________________

Claims Address:  ____________________________________________________________________________
                    street                         city                     state                     zip
Policy #:  __________________________________________ Group #:  _______________________________

Please check “YES” or “NO”

YES    NO        
[   ]    [   ]    Have had recent medical treatment of illness; describe:  _________________________________

[   ]    [   ]    Have allergies; describe:                Date of Last Tetanus Shot:___________   

[   ]    [   ]    Have physical conditions requiring special consideration; describe:                
        
        ______________________________________________________________________________   

[   ]    [   ]    Will have medication at camp.  (must be in original prescription container labeled with Staff’s
                  name, medication name, dosage, time taken);
List:  _________________________________________________________________________
    Staff under 18 years old must turn in all medications to the camp nurse.

[   ]      [   ]      Have you recently been exposed to, or shown any symptoms of, any contagious disease,
                       such as, but not limited to:  the flu, chicken pox, SAARS, head lice?
                       If yes, please explain:  _________________________________________________________
 NOTE:  For the safety of our campers and staff we must quarantine anyone with symptoms of a
 contagious disease, and will send them home upon confirmation of the diagnosis.
           
MEDICAL CONSENT FOR STAFF UNDER 18 YEARS OF AGE

IN CASE OF MEDICAL EMERGENCY, I understand every effort will be made to contact parents or legal guardians of minor staff.  In the event I cannot be reached, I hereby give my permission to Lake Lundgren Bible Camp’s administration to seek professional medical attention including hospitalization, securing proper treatment, and ordering injection, anesthesia or surgery for my child.

Parent/Legal Guardian’s Signature:  ______________________________ Date: _____________________