J2K Ministries Staff Medical Form

*Denotes Required Field

Please fill out the following medical information and submit this form along with your staff application.

If you have any questions, please contact Aaron Harbidge at director@j2kministries.ca or by phone at 587-321-0066.

Thanks so much!
Aaron Harbidge
J2K Ministries Director

Contact Information:

Address:

Phone: ( ) -

Email:

Medical Information:

In case of serious accident or illness every person must be covered by the Alberta Health Plan or an equivalent policy. If you do not have medical coverage, please note it below.

Health Care #:

Describe your current medical plan if other than provincial medical coverage:

Family Doctor:

Doctor's Phone:

Date of last tetnus shot (if applicable):

Special Dietary Requests:

Non-allergy – Please list all non-allergy requests and reasons:

Allergy Related – List food allergies, reactions and remedies. Please be specific:

Others details regarding the need for further medical attention?

Medications:

Our First Aid department generally stocks basic over-the-counter medications. We will carry a current Epi-pen, but staff with Epi-pen prescriptions should bring their own. *Any medications you bring must be in the original container. Prescriptions may only be used by the person for whom they are prescribed.

Please list any over-the-counter meds to which you oppose being given:

Prescriptions currently being taken - please provide need-to-know information:

Other Conditions:

Recent operations we should know about?

Illnesses/injuries receiving medical attention in the last year?

Recent contagious contact (i.e. chicken pox, flu)?

Please describe any health restrictions, mental health concerns, or educational needs:

Waiver and Signature:

If under 19 years old, then the Parent/Guardian must read and sign the following: I recognize that camp activities involve a degree of spontaneity and risk, and that accidents may occur. I am aware of the types of activities at the camp my child is attending, and I accept the risks of possible injury. Should injury require emergency treatment, which would be delayed by efforts to contact me, I hereby grant permission to the Camp Director or First Aid Attendant to authorize medical treatment and inform me as soon as possible.

Signature of Applicant: Use your mouse or finger to sign here

Date Signed:

Signature of Guardian, if required: Use your mouse or finger to sign here

Medical Notes for 1st Aid Personal only:

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