To Be Completed By Employee or Employee’s Guardian for every year of employment.
Please Mail this form back to Meadowbrook within 30 days of receiving it.

Personal Information

First Name

Last Name

Date of Birth (MM/DD/YYYY)

Gender

HeightEmail Address

Weight

Street Address

City

State

Zip

Home Phone Number

Cell Phone Number

Emergency Contact #1

Relationship

Emergency Contact #1 Phone

Emergency Contact #1 Cell

Emergency Contact #2Emergency Contact #2 Phone

RelationshipEmergency Contact #2 Cell

Emergency Medical Information

Please check any that apply:AsthmaConvulsionsFainting SpellsHigh Blood PressureContact LensesDiabetesHeart TroubleMigraine Headaches

Allergy or reaction to any medicine, food, plants, and/or animal/insect toxin?YesNo

If yes, please explain.

Any other condition that may require emergency or special care, medicine or knowledge?YesNo

If yes, please explain.

Insurance Information

Insurance Carrier/Plan Name:

Insurance Carrier Address:

Insurance Policy Number:

Group Number:

Prescription Plan #:

Medical Contact Information

Physician:

Phone:

Dentist:

Phone:

Name of Camp 3

Position

Town

Zip Code

Years

Salary

Medical History

Any Past or Present History of:

Employer's Name 2

Phone Number

Address Line 1

Address Line 2

Town

Zip Code

State

Dates of Employment

Add a third employment experience?YesNo

Employer's Name 3

Phone Number

Address Line 1

Address Line 2

Town

Zip Code

State

Dates of Employment

Back, Limbs, JointsYesNo

Behavioral ConditionYesNo

Braces / RetainerYesNo

Chest, LungsYesNo

Contact LensesYesNo

DeformityYesNo

EarsYesNo

EyesYesNo

Head Injury/ConcussionYesNo

Hearing AidYesNo

HeartYesNo

Heart MurmurYesNo

HerniaYesNo

Immune DeficiencyYesNo

KidneysYesNo

Menstrual ProblemsYesNo

Nose / NosebleedsYesNo

Physical LimitationsYesNo

Pneumonia (recurrent)YesNo

Rheumatic FeverYesNo

Serious IllnessYesNo

Serious InjuryYesNo

SinusYesNo

Skin, GlandsYesNo

Stomach, BowelsYesNo

SurgeryYesNo

TeethYesNo

TonsilsYesNo

Urine InfectionYesNo

Other (explain below)YesNo

Please explain any Yes answers

Are you currently under medical care?

YesNo

If Yes, Explain

Do you take any medication?

YesNo

If Yes, Explain. Please include if this might impair your ability to perform the essential functions of your position.

Date of Most Recent Tetanus Shot:

Authorization

To the best of my knowledge, the medical history is correct and complete and all immunizations are up to date. I know of no reason to restrict activity and give my permission for participation in all activities. I give permission for a Meadowbrook Country Day Camp staff member to administer an emergency Epi-Pen if deemed necessary. In the event I cannot be reached in an emergency, I hereby give permission to Meadowbrook Country Day Camp to take me/my child to the hospital or any outside physician selected by the camp when deemed necessary. Furthermore, I hereby give permission to such hospital or physician to hospitalize, secure proper treatment for, and/or order x-rays, routine tests, medications, injections, anesthesia and/or surgery for me/my child named above, without limitations. I understand that all medical bills for services rendered by anyone other than the camp’s medical staff are my responsibility. I authorize the release of any medical information or records related to treatment, referral, billing or insurance purposes related to me/my child.

I further authorize the camp medical staff to discuss any medical conditions with the Director, his/her designee, or my/my child’s supervisor when the medical staff, in its sole discretion, believes such communication to be in my/my child’s best interest.Staff Member Electronic Signature (print name)

(to be signed by parent or guardian, if staff member is under 18 yrs of age)

Date

If Under 18, Parent or Guardians Printed Name, Address, Phone Number(s)