CC Crew Registration Form

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COMMUNITY CAMP CREW REGISTRATION FORM

First Name

Last Name

Phone Number

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Please select your campus:

Gender

Male

Female

Birthdate

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone Number

Medical Conditions

Our Crew is vital to our camp, therefore the Crew’s health is just as important as the health of our campers! It is our desire to care for each member of the Crew well and, if the need arises, provide excellent medical support in any emergency situations. In order to do so, it is important that our Medical Crew be aware of any major medical conditions our Crew might have. Confidentiality of medical information is of utmost importance and will only be shared with the Medical Crew and key administration that have a need to know.

Below is a list of Medical Conditions. Check any conditions you have and complete the follow up questions for each condition thoroughly. If you have any questions or concerns, please contact our Medical Ministry Team Lead, Tracy Cordonnier at 936-417-4617.

I have a medical condition listed below:

Yes

Please select all that apply:

High Blood Pressure

Heart Conditions (Arrhythmia, Coronary Heart Disease)

Asthma

Respiratory Conditions (COPD, CF)

Diabetes

Seizure Disorder

Anaphylactic Allergies

Other Conditions the Medical Crew Should Be Aware Of

NONE: I have no known Medical Conditions.

High Blood Pressure: Any issues with this condition in the last 6 months?

Yes

High Blood Pressure: Do you take daily medications for this?

Yes

High Blood Pressure: Name(s) of Medication

High Blood Pressure: Dose

High Blood Pressure: Frequency

Name of Heart Condition

Heart Condition: Any issues with this condition in the last 6 months?

Yes

Heart Condition: Do you take daily medications for this?

Yes

Heart Condition: Name(s) of Daily Medication

Heart Condition: Dose

Heart Condition: Frequency

Asthma: Describe Triggers.

Asthma: Do you have daily or rescue medications for this?

Yes

Asthma: Name(s) of Medication

Asthma: Dose

Asthma: Frequency

Name of Respiratory Condition

Respiratory Condition: Any issues with this condition in the last 6 months?

Yes

Respiratory Condition: Do you take daily medications for this?

Yes

Respiratory Condition: Name(s) of Medication

Respiratory Condition: Dose

Respiratory Condition: Frequency

Diabetes: Type

Diabetes: Any issues with this condition in the last 6 months?

Yes

Diabetes: Do you take daily medications for this?

Yes

Diabetes: Name(s) of Medication

Diabetes: Dose

Diabetes: Frequency

Seizure Disorder: Type

Seizure Disorder: Describe

Seizure Disorder: Last Seizure

Seizure Disorder: Do you take daily or rescue medications for this?

Yes

Seizure Disorder: Name(s) of Medication

Seizure Disorder: Dose

Seizure Disorder: Frequency

Allergic to:

Anaphylactic Allergies: Describe Reaction

Anaphylactic Allergies: Last Reaction

Anaphylactic Allergies: Do you take daily or rescue medications for this?

Yes

Anaphylactic Allergies: Name(s) of Medication

Anaphylactic Allergies: Dose

Anaphylactic Allergies: Frequency

Name of Other Condition

Other Condition: Any issues with this condition in the last 6 months?

Yes

Other Condition: Do you take daily medications for this?

Yes

Name of Medication(s)

Dose

Frequency

Date Input

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Contact Us

Mailing: 400 N Commerce Street, Lewisburg, OH 45338
Community of Faith Office: 219 N Commerce Street, Lewisburg, OH 45338
Phone: (937) 583-5205