Emergency Form for
Camp Staff
Name Date / /
Last First Middle
Primary Emergency Contact:
Name Relationship
Address
City State Zip
Phone (Work) Phone
(Home)
Alternate Emergency contact:
Name Relationship
Phone (Work) Phone
(Home)
Basic Health Information:
Current Medications
Allergies
Other Conditions/Limitations we should be aware of
Health Care Provider and Insurance
Information:
Health Care Provider
Clinic Name
Address
City State Zip
Phone
Insurance Company Member/Policy Number