SOUTH SHORE CONGREGATIONAL YOUTH CONFERENCE

"A Vacation with a Purpose"

SUMMER CAMP

STAFF INFORMATION AND MEDICAL/RELEASE FORM

STAFF MEMBER INFORMATION

First Name Middle Name Last Name Suffix Gender M F

Current Street Address City State Zip Code

Home Phone (XXX-XXX-XXXX) Mobile Phone (XXX-XXX-XXXX)

Date of Birth (MM/DD/YYYY) T-Shirt Size

HEALTH INSURANCE INFORMATION

Insurance Company

Policy Number Group Number

Policy Holder (Parent if Applicable) Policy Holder Date of Birth (MM/DD/YYYY)

PRIMARY CARE PHYSICIAN

Name Practice Phone Number (XXX-XXX-XXXX)

Street Address City State Zip Code

EMERGENCY CONTACTS

CONTACT 1

Name Relationship

Home Phone (XXX-XXX-XXXX) Mobile Phone (XXX-XXX-XXXX)

CONTACT 2

Name Relationship

Home Phone (XXX-XXX-XXXX) Mobile Phone (XXX-XXX-XXXX)

GENERAL HEALTH INFORMATION

General Health Condition (Check One) Excellent Good Fair Poor

Date of Last Tetanus Immunization (MM/DD/YYYY)

List any allergies (including drugs, environment and latex)

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List any food allergies

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List any dietary restrictions

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List any medical concerns or conditions (asthma, depression, diabetes, anxiety, nosebleeds, etc.)

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List any current medications

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Email Address

The completed form form will be sent to you by email (above address).
You must print this form out, sign it, and send it to:

SSCYC, INC.
Attn: Staff Applications
P.O. Box 890008
Weymouth, MA 02189-0001

SOUTH SHORE CONGREGATIONAL YOUTH CONFERENCE

"A Vacation with a Purpose"

SUMMER CAMP

STAFF INFORMATION AND MEDICAL/RELEASE FORM

STAFF MEMBER INFORMATION

HEALTH INSURANCE INFORMATION

PRIMARY CARE PHYSICIAN

EMERGENCY CONTACTS

CONTACT 1

CONTACT 2

GENERAL HEALTH INFORMATION

The completed form form will be sent to you by email (above address). You must print this form out, sign it, and send it to: SSCYC, INC. Attn: Staff Applications P.O. Box 890008 Weymouth, MA 02189-0001

The completed form form will be sent to you by email (above address).
You must print this form out, sign it, and send it to:

SSCYC, INC.
Attn: Staff Applications
P.O. Box 890008
Weymouth, MA 02189-0001