Summer Staff Medical Form 2020

All applicants must fill this out before volunteering with us.
  • If parent cannot be reached
  • Insurance Carrier

    His Hill provides insurance as secondary coverage
  • Health History

    Check yes or no if you ever had in the past or are presently being treated for any of the following conditions:
  • Immunization

  • Activity and Treatment Authorization

    This health history is correct so far as I know, and give my consent to engage in all school/camp/athletic activities, except as noted by me and my physician. I hereby give permission to the staff at His Hill to secure and administer medical treatment, as they deem appropriate, including hospitalization. I also give my permission to the medical personnel selected by His Hill to order x-rays, routine tests and treatments. If hospitalized, I give permission for the His Hill staff to act on my behalf, and represent my family in their absence.
  • I authorize with my electronic signature for His Hill Ranch Camp. (Signed by student/summer staff above 18 years old. Parent/guardian signed if applicant is under 18 years old)
  • Date Format: MM slash DD slash YYYY