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Parent Tools/Advice

Home
About CCK
Virtual Tour
Become a Camper
Get Involved
Donate
- US Dollars
- Planned Giving
Parent Tools/Advice

Medical History Form

Session Attending*
Please indicate what position you are applying for.*
If Other, please indicate what position you are applying for.*
Name*
Date of Birth*
Age*
Gender*
- Male
- Female
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Telephone Number*
Cell Phone Number*
Email*
Emergency Contact
Name*
Relationship to You*
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Home Phone*
Work Phone*
Medical Information
Height*
Weight*
Last Tetanus Booster*
Significant Medical History*
surgery, serious injuries, hospitalization
- Yes
- No
Please List:*
Allergies*
medication, food, and contact items like insect bites
- Yes
- No
Please List:*
Physical Restrictions or Limitations to Activity*
- Yes
- No
Please List:*
Prescription Medications*
Prescription medications or over the counter medications: (Summer counselors will have meds stored in the medical center.)
- Yes
- No
Please List:*
Primary Care Physician*
Telephone Number*
Medical Release
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.
Digital Signature: Applicant's Name*
Date*
MM slash DD slash YYYY
If under the age of 18, signature of parent or legal guardian is required.
Digital Signature: Applicant's Name*
Date*
MM slash DD slash YYYY
The Center for Courageous Kids Tuberculosis (TB) Risk Factors Screening
Have you had an unexplained fever, poor appetite, persistent cough, night sweats, fatigue, spitting up blood, or unexplained weight loss in the past year?*
- Yes
- No
Are you an immigrant from OR have traveled to a country (within the last year) with a high incidence of TB? (Caribbean, Latin America, Africa, and Asia, excluding Japan.)*
- Yes
- No
Have you had household contact with an individual who immigrated from a country with a high incidence of TB (Caribbean, Latin America, Africa, and Asia, excluding Japan) or an individual who has TB?*
- Yes
- No
Have you had exposure to individuals in the past year who are HIV-infected, homeless, institutionalized, users of illicit drugs, or incarcerated?*
- Yes
- No
Do you have HIV infection, chronic renal failure, malnutrition, reticuloendothelial diseases, other immunodeficiencies, or receiving immunosuppressive therapy?*
- Yes
- No
I have previously tested positive on a TB skin test.*
- Yes
- No
Please attach copy of Chest xray.*
Max. file size: 50 MB.
If you answered YES to any of the questions above, please submit documentation of a TB skin test (Mantoux). If the TB skin test is positive, you will need to submit evidence of a chest x-ray report. You can submit these results via e-mail to Volunteer Recruiter, Melissa Gerard at mgerard@courageouskids.org. If you answered NO to all the above questions, you will not need to submit an additional documentation.

Please Sign Below:
I have none of the identified risk factors.*

Δ

Courageous Partners

Gold Ribbon Camp Accredited

ADDRESS
1501 Burnley Road
Scottsville, KY 42164

PHONE
270.618.2900

EMAIL
info@courageouskids.org

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