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Volunteer Health History Form

Name

Birthday

Gender

Age

Multi-line address

Country/Region

Address

City

Zip / Postal code

Primary phone

Secondary Phone

Family medical/Hospital insurance carrier

Policy or group number

Emergency Contact #1

Relationship

Daytime Phone

Evening Phone

Emergency Contact #2

Relationship

Daytime Phone

Evening Phone

Health History Record (check all that apply)

Chronic or recurring illnesses

Heart Defect/Disease

Seizures

Bleeding/Clotting

Asthma

Diabetes

Other

Any restrictions concerning physical activities?

Yes

No

Please describe any conditions

Allergies

Food/Nuts

Insect Stings

Medicine/Drugs

Other/Specify

Special dietary restrictions?

Date of last Tetanus booster (year)

Please list any medications taken on a daily basis, including over-the-counter medications

Any other relevant health concerns?

I verify that this health history is complete and accurate. I am able to engage in all prescribed activities, except as noted.

Signature

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Date

Our Location

Battle Ground, WA

Contact Us

GENERAL QUESTIONS: campjuliannadirector@gmail..com

REGISTRATION

juliannaregistrar@gmail..com

We Accept

Camp Julianna is a volunteer-run summer day camp associated with Girl Scouts of Oregon & SW Washington

9620 SW Barbur Blvd. Portland, OR 97219

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