Staff Medical Release

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Alto Frio Baptist Camp & Conference Center

Alto Frio Staff Medical Release Form

Employee Name*

Prefix (optional)

First Name

Initial (optional)

Last Name

Suffix (optional)

Employee Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Employee Sex*

Employee Date of Birth*

Employee Age*

Employee Email*

Employee Phone*

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Parent/Guardian Name*

Prefix (optional)

First Name

Initial (optional)

Last Name

Suffix (optional)

Parent/Guardian Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Parent/Guardian Phone*

Parent/Guardian Alternate Phone

Parent/Guardian Email Address

Spacer - Copy

Emergency Contact #1 - Name*

First Name

Last Name

Emergency Contact #1 - Phone*

Emergency Contact #1 - Relationship

Spacer - Copy - Copy

Emergency Contact #2 - Name*

First Name

Last Name

Emergency Contact #2 - Phone*

Emergency Contact #2- Relationship

Spacer - Copy - Copy - Copy

Emergency Contact #3 - Name*

First Name

Last Name

Emergency Contact #3 - Phone*

Emergency Contact #3- Relationship

ALLERGIES

Food allergies*

Medication allergies*

Other allergies*

MEDICATIONS

Prescription Medications

Medications MUST be in the original medication prescription bottle.

The medication prescription bottle MUST match what the camper actually takes AND match the camper’s name that is on the Medical Release Form.

Examples:

(1) Atenol 50mg one tab daily But, the camper states: I only take ½ of that pill.

(2) Synthroid 137mcg one at bedtime But, the camper states: I take it in the morning not at bedtime.

The camper will be given medication as stated on the prescription.

All medications must be in date and not expired. Including Epi-Pens, Inhalers, Nebulizer Medications & Insulin.

Medication #1 : Name

Medication #1: Dosage

Medication #1: Time Given

Medication #1: Special Instructions

Medication #2 : Name

Medication #2: Dosage

Medication #2: Time Given

Medication #2: Special Instructions

Medication #3 : Name

Medication #3: Dosage

Medication #3: Time Given

Medication #3: Special Instructions

Medication #4 : Name

Medication #4: Dosage

Medication #4: Time Given

Medication #4: Special Instructions

Additional Medications - If you have additional medications, please list Name, Dosage, Time, and Special Instructions here.

File Uploads

If you have a copy of a doctor's instructions or other important documents, please upload a scan or a picture here.

Document 1

No File Chosen

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Document 2

No File Chosen

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Document 3

No File Chosen

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CONSENT

In consideration for your agreeing to accept the above named individual as an employee, I hereby give my authority and consent to medical and surgical treatment as may be needed in the judgment of the treating physician chosen by the Alto Frio Administrator or the administrator's representative.

I also understand that all medications must be in original prescription bottles, no loose pills will be accepted and that the name on the prescription bottle must match the name on this form and all medications must be listed on this form. I further understand that should I send medications that do not meet these guidelines, that these medications WILL NOT be allowed on campus.

Please initial (Parent/Guardian)*

I, as parent or guardian of the camper specified above, authorize the Alto Frio Camp Medical Professional to distribute any prescribed and/or over-the-counter medications to my child that meet the above mentioned guidelines.

Please initial (Adult Employee)*

I, the camper specified above, authorize the Alto Frio Camp Medical Professional to distribute any prescribed and/or over-the-counter medications that meet the above mentioned guidelines.

Parent/Guardian Signature*

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Employee Signature*

[clear]

Printed Signature Name*

First Name

Last Name

Date*

MEDICAL INFORMATION REQUESTED

ALLERGIES

MEDICATIONS

Prescription Medications

File Uploads

DIETARY INFORMATION

CONSENT