The SayPro Health and Safety Form is designed to collect essential health-related information from participants in order to ensure their safety, comfort, and well-being throughout the 5 Days Religious Studies Camp. This form will help SayPro provide a supportive environment for all participants, whether they are attending in person or virtually.
Health and Safety Form
1. Participant Information
- Full Name:
(First Name, Last Name) - Date of Birth:
(MM/DD/YYYY) - Phone Number:
(Emergency contact number) - Email Address:
(Primary contact)
2. Emergency Contact Information
- Emergency Contact Name:
(Full Name of the person to contact in case of emergency) - Relationship to Participant:
(e.g., parent, sibling, friend, spouse) - Emergency Contact Phone Number:
(Phone number of emergency contact)
3. Medical History and Current Health Status
- Do you have any chronic health conditions?
☐ Yes
☐ No If yes, please specify: - Do you have any of the following conditions?
(Check all that apply)
☐ Asthma
☐ Diabetes
☐ Heart Conditions
☐ Epilepsy
☐ High Blood Pressure
☐ Allergies
☐ Other: ____________ - Are you currently taking any medications?
☐ Yes
☐ No If yes, please list the medications and dosages: - Do you have any food allergies or sensitivities?
☐ Yes
☐ No If yes, please list them: - Do you have any environmental allergies (e.g., pollen, dust, etc.)?
☐ Yes
☐ No If yes, please specify: - Are you allergic to any medications?
☐ Yes
☐ No If yes, please list the medications:
4. Physical Activity and Accommodation Needs
- Are there any physical activities or exercises that you should avoid due to health concerns?
☐ Yes
☐ No If yes, please specify: - Do you require any special accommodations for participation in camp activities?
☐ Yes
☐ No If yes, please describe: - Do you have any mobility or accessibility concerns?
☐ Yes
☐ No If yes, please explain: - Do you have any mental health concerns or conditions that we should be aware of?
☐ Yes
☐ No If yes, please specify:
5. Emergency Medical Treatment Authorization
- In case of a medical emergency, do you authorize SayPro staff to seek immediate medical treatment if necessary?
☐ Yes
☐ No - Do you have a preferred healthcare provider or hospital for emergencies?
☐ Yes
☐ No If yes, please provide their details:
6. Health and Safety Guidelines Acknowledgment
- Health and Safety Protocols
By attending the camp, I agree to follow all health and safety guidelines outlined by SayPro and adhere to any COVID-19 safety protocols (if applicable), including wearing masks, social distancing, or other necessary precautions.
☐ I agree - Participant Health Status Declaration
I confirm that the information provided in this Health and Safety Form is accurate and up-to-date to the best of my knowledge. I will notify SayPro immediately if any changes to my health or medication occur before or during the camp.
☐ I agree
7. Additional Health Considerations
- Is there anything else we should know about your health or medical needs to ensure your safety and comfort during the camp?
(Please specify any other relevant information)
8. Signature and Consent
- Participant’s Signature:
(Sign below to confirm that all information provided is accurate and complete) - Date:
(MM/DD/YYYY) - Parent/Guardian Signature (for minors):
(If the participant is under 18, the signature of a parent or guardian is required) - Date:
(MM/DD/YYYY)
Thank you for completing the Health and Safety Form!
We appreciate your attention to detail in completing this form. Your health and safety are important to us, and the information you have provided will help ensure a safe and supportive environment throughout the SayPro 5 Days Religious Studies Camp. Should any of your health circumstances change or if you have additional concerns, please do not hesitate to contact us.
This Health and Safety Form Template allows SayPro to gather all necessary medical, dietary, and emergency contact information from participants to create a safe environment during the 5 Days Religious Studies Camp. By collecting relevant data, we ensure that the camp staff can respond effectively to any health concerns or emergencies that may arise.
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