Medical History Form

  • MM slash DD slash YYYY
  • Emergency Contact
  • MM slash DD slash YYYY
  • Prescription medications or over the counter medications: (Summer counselors will have meds stored in medical center.)
  • In case of accident or illness, medical services may be provided by camp medical/nursing staff. In the event of an emergency and you are unable to give consent for care, the medical center staff is authorized to carry out any procedures deemed necessary. Staff members and volunteers assume financial responsibility for all medical expenses incurred while at camp. Medical insurance information is requested in the event a referral of an injured or ill staff/volunteer becomes necessary. I have read, understand and agree by the above. I attest that I am physically fit for camp and there are no medical restrictions that would prevent me from performing the essential functions of my job. I understand that The Center for Courageous Kids assumes no responsibility for any pre-existing injury or illness.
  • The Center for Courageous Kids Tuberculosis (TB) Risk Factor Screening
  • If you answered YES to any of the questions above, please submit documentation of a TB skin test (Mantoux) with your medical form. If the TB skin test is positive, you will need to submit evidence of a chest x-ray report. If you answered NO to all the above questions, please sign below: