NOT TO BE USED BY COOKING STAFF

This form is only to be used for those returning staff members who will be working all session.

Staff Information
First Name
Middle Name
Last Name
Maiden Name
Date of Birth
Race
Sex
Shirt Size
Phone Number
Street Address
City
State
Zip Code
Driver's License Number
Cell Phone Number
Email Address
List of all current medications:    
Name
Frequency
Dosage

Please note if you are assigned to a cabin you must leave all medications including Non-prescription medications in the infirmary. Staff assigned to the Big House may keep their own medications. The only EXCEPTION to this rule for cabin staff is BCP.

Do you have any of the following illnesses or health conditions?

Yes
No
  
Hay fever, asthma, or wheezing
High or Low Blood pressure - Diabetes
Heart problems
Seizures
Back problems
Headaches
Any type of emotional problems including depression
Are you pregnant?
Do you have any type of contagious or infectious disease?
Do you have any other health issues that we should be aware of?
    Please describe anything that you answered yes to above.
Are you currently being treated by a physician for any medical conditions? Yes No
If yes please specify
Do you have any allergies?

Yes No
If yes please specify and describe symptoms if exposed.
Are you allergic to any medication? Yes No
If yes please specify
Have you ever been convicted  of any thing other than a minor traffic violation
I authorize Great Lakes Burn Camp, Inc. to conduct a background check with the State Police and/or appropriate authorities for the purpose of determining my suitability for volunteer staff with Great Lakes Burn Camp, Inc.
Initials
Today's Date
 


PO Box 6189, Jackson MI 49204-6189 - 1-800-989-2571