True Friends
10509 108th St NW
Annandale, MN 55302
Tel: 952.852.0101 Fax: 952.852.0123
Email: jobs@truefriends.org
Website: www.truefriends.org
TRUE FRIENDS STAFF & VOLUNTEER
EMERGENCY CONTACT, HEALTH HISTORY & IMMUNIZATION RECORD
NAME:_______________________________ ________________________
SEX: Female______ Male______
last
first
ADDRESS:________________________________________________
CELL PHONE:
CITY:_________________________ STATE:________ ZIP:_________
HOME PHONE: (______) __________________
(______) __________________
BIRTHDATE: ______/______/______ Are you under the age of 18? Yes _____ No ______ (If so you must have a parent
or guardian sign the release form on the bottom of the back page)
IN CASE OF EMERGENCY NOTIFY
NAME:_________________________________________________
RELATIONSHIP:__________________________
ADDRESS:_______________________________________________
CELL PHONE:
CITY:_________________________ STATE:________ ZIP:________
HOME PHONE: (______) __________________
(______) __________________
WORK PHONE: (______) __________________
SECOND EMERGENCY CONTACT
NAME:_________________________________________________
RELATIONSHIP:__________________________
ADDRESS:_______________________________________________
CELL PHONE:
CITY:_________________________ STATE:________ ZIP:________
HOME PHONE: (______) __________________
(______) __________________
WORK PHONE: (______) __________________
If under the age of 18, please complete the following:
PARENT/GUARDIAN NAMES & EMPLOYMENT
NAME:_________________________________________________
RELATIONSHIP:__________________________
ADDRESS:_______________________________________________
CELL PHONE:
CITY:_________________________ STATE:________ ZIP:________
HOME PHONE: (______) __________________
(______) __________________
WORK PHONE: (______) __________________
NAME:_________________________________________________
RELATIONSHIP:__________________________
ADDRESS:_______________________________________________
CELL PHONE:
CITY:_________________________ STATE:________ ZIP:________
HOME PHONE: (______) __________________
(______) __________________
WORK PHONE: (______) __________________
**INSURANCE: Please remember to bring your health insurance card with you to camp so that in the event you need to
be seen offsite you can provide this information to the health care facility. **
COMPLETE back page
Camp__________ Position _____________ Seasonal ____ Year round_______
Seasonal\HC\HC forms\Health History\9-2013
ALLERGIES: Please list ALL allergies (environmental, medication, & Food related): _______________________________
__________________________________________________________________________________________________
Describe reactions: Please circle any of the following:
hives
difficulty breathing
other_______________________________________________
Do you carry an Epi-pen or kit for treatment of allergic emergencies? Yes______
No______
Special DIET/Restrictions: We are happy to accommodate the following special dietary needs with a minimum three week
notice.
 Vegetarian
Gluten Free Lactose Free Diabetic  Other/ Special Instructions:
____________________________________________________________________________________________________________________
**If you have any other special diets, we will do our best to accommodate however, we recommend bringing in your own food to supplement our
meals.
*Please note that the vegetarian options provided at camp may be prepared with milk/eggs/cheese. The food service department may not be
able to accommodate all individual tastes and needs. Gluten Free diets are prepared in a NON- Gluten Free kitchen and cross contamination could happen.
TETANUS HISTORY: Please give date (month/year) of most recent tetanus shot/ Booster: _____________
PHYSICAL: Are you capable of meeting the physical requirements of your position as outlined in your job description and
discussed with your supervisor? Yes _____ No _____
CURRENT MEDICATIONS/CONDITIONS: **If at any time during the course of your employment you begin taking a
medication or have a condition that may affect your ability to perform your job functions please discuss this with the
camp nurse or Director of Health care. **
This health history is true and complete to the best of my knowledge. EMERGENCY INFORMATION: I give permission to the medical personnel selected by True
Friends to provide routine health care, administer camp standing orders and to seek emergency medical treatment. I also give permission for the True Friends health
care personnel to administer prescribed medications in the event that I am not capable. I agree to the release of any records necessary for medical & insurance
purposes. I give permission for necessary related transportation. In the event that the emergency contact cannot be reached in an emergency, I hereby give
permission to the health care facility selected by the camp to secure and administer treatment including but not limited to; hospitalization, injections, routine tests,
X-rays, anesthesia or surgery, for the person named on this form. If I/my child is released to True Friends, the camp has permission to obtain copies of my/my child’s
treatment and health record from any provider who treats me/my child. I understand that the information about me/my child’s health will be obtained only as
needed and shared on a “need to know” basis with camp staff. I will notify True Friends in writing of any health related changes between the date of this form and
my/my child’s arrival at camp.
Signature of Staff/Volunteer member:__________________________________________Date:______/______/______
__________________________________________________________________________Date:______/______/______
Signature of parent/guardian if staff/volunteer staff member is under age of 18: