Staff Medical Form Name* First Last Gender*FemaleMaleAge*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Guardian/Emergency Contact Name*Guardian/Emergency Contact Phone Number (Put 2 in blank if possible)*Have you had any of the following or do you currently have any of the following?* None of the below Allergies Medications (including over the counter medicines) A concussion or a history of concussions** Life threatening conditions** Disability** A ailment that is currently contagious** Rheumatic Fever Rubella *Mark all that apply. **If you mark one of these, please give us more information in the box below.Further Information about the above medical conditions (if any)Allergies List all allergies below   Edit Delete There are no Entries. Add Entry Medications Medications Upload Doctor's Orders   Edit Delete There are no Entries. Add Entry Insurance CarrierName of InsuredInsurance Policy NumberImmunization RecordPlease take a picture or scan in your immunization record and upload it here.Terms of ServiceIn case of an emergency, I understand that every effort will be made to contact the emergency contact or guardian while providing care for me/my child. I understand that emergency care will not be delayed while trying to reach the emergency contact or guardian. In the event that me or my contact cannot be reached, I give permission to the physician selected by the Camp Administrator or Camp Nurse to secure treatment for, hospitalize, order injection, anesthesia or surgery for the above named staff member. The health history and all the other information given above is correct to the best of my knowledge. The staff member named has permission to engage in all camp activities, unless otherwise noted to Nurse or Administrator, including but not limited to, group games, climbing wall, swimming, archery, knife skills, baking, etc. This staffer also has my permission to ride the zip line(s) and I have read and understand the information on the Zip Line Course Rules, Risks, and Waiver Form. I certify that this staffer can work at camp and any pictures of them may be used for future promotion of the camp. Also, by checking the box below, I hereby agree that I/this staffer will be expected to abide by the policies, procedures, rules, standards of conduct, and religious values of the Independent Baptist Camping Association. Failure to do so, may result in dismal from the campus. If I/this staffer is dismissed, I, the staffer or guardian, will be responsible to pick up the staffer from the camp or see that they are picked up from camp. Any further expense incurred by the staffer as a result of dismissal will be fully my responsibility, including any necessary transportation expenses. I (or my parent or guardian if I am not 18 years old or older) agree to the permissions and provisions above Permission giver's name*Please type your legal name here (if you are 18 or older you may do this for yourself, if you are under 18, your parent or guardian needs to give permission for the above and type their name in this blank).