Chaperone/Work Crew Medical Form

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Chaperone/ Work Crew Member Medical Information

The information collected in this form will be used solely for chaperone and work crew safety during camp. The information is confidential and shared only with healthcare professionals at camp and relevant PCC staff members.

First Name *

Last Name *

Email Address *

Is this form for a chaperone or work crew member? *

Emergency Contact Name (first & last) *

Emergency Contact Phone Number *

Any medication allergies? If so, what reaction?

In case of sickness or accident, we give permission for medical attention and treatment as deemed needed by healthcare professionals be administered. *

Yes

If you selected 'No' above, please explain so we know best how to help in an emergency. *

Check all that apply: The medical staff on duty has permission to administer the following to the above named volunteer: *

Acetaminophen (Tylenol)

Ibuprofen (Advil)

Tums (Upset stomach)

Antibiotic Cream (Neosporin)

Benadryl (Allergy Med)

Meclizine (Nausea Medication)

List all active prescriptions with medication name, dose, and frequency *

Acknowledgement: ANY rescue medication should always accompany chaperones and work crew members for PCC travel. Rescue medication is life-saving medication such as Epi-pens, Auvi-Q, inhalers, diabetic or seizure medications.

I understand and agree that all rescue meds prescribed will go to camp and MUST be carried on the volunteer at all times.. *

Yes

Phoenix Children's Chorus

Chaperone/Work Crew Medical Form