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Medical Information Form – Staff

THIS FORM IS DUE BY June 9, 2024.

All fields with a green * are required.

It is recommended that you submit the form via computer or tablet. Some are having difficulties using a smart phone.

  • Please complete the table with any drug, food, or environmental allergies. If there is not enough room, please provide additional information in the box below the table.

  • Please check any of the following that apply.
  • Please use the space below to explain any item checked above or any other health-related issue that would be helpful in providing care.
  • Please use the space below to add any additional medication/dosage information, if needed.
  • MM slash DD slash YYYY
  • Consent to treat: I hereby designate
  • to provide, seek, and consent to routine health care, administer prescribed medications, administer over-the-counter-medications as necessary, and emergency treatment for me as may be necessary, including, but not limited to x-rays, routine tests and treatment, and/or hospitalization. I also give permission to him/her to arrange related transportation. The attending provider, appropriate staff, and Camp Areté, its officers, regents, and employees shall not be responsible in any way for any consequences from said diagnostic, medical and or surgical treatment and are hereby released from any and all claims and causes of caution that may arise, grow out of or be incident to such diagnosis, treatment, or surgery insofar as the law allows and provided that these services are performed with ordinary care and to the best of their ability.
  • Consent to render payment: Should medical care beyond the capabilities of camp staff be required for my care, I agree to assume responsibility for the payment of these services.
  • MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.