2018 Staff Assistant Application and Agreement


Parent/Guardian/Responsible Party

Emergency Contacts
Please list 2 emergency contacts if parent/guardian cannot be reached.

Health Care Providers

Please upload a copy of the front and back of volunteer's insurance card.

Allergies (including food, medication, and environmental)
Please specify the type of reaction for each allergy and the remedy.
Allergen Reaction Severity Remedy
(e.g., bee stings)
(e.g., anaphylaxis)
(e.g., give Benadryl and call 911)
General Health Information
Please provide any pertinent medical information that the Camp PARC staff should be aware of in case of an emergency.


(e.g., mg, units; not # tabs)

(e.g., by mouth, inhaled)

Medication Policy: It is the policy of Camp PARC that all medicines are kept in a locked area. It is the responsibility of the staff person to inform a nurse when a regular medication is required. At that time the nurse will obtain the staff person's medications from the secured area and the staff person will self administer any medication.
Non-Prescription Medications
The following non-prescriptions medications are stocked in the camp Health Center and are used on an as needed basis to manage illness and injury. Please review the list below and select which medications the staff member is able to receive.
Health Care Authorizations