Summer Staff Health Form 2023

Legal Name (for payroll):*

First Last

Preferred Name:

Date of Birth*

Gender*

Male
Female

T-Shirt Size:*

Sweatshirt Size:*

Parents'/Guardians' Names*

Parents' Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Parents' Address (if separate address- specify mother or father)

Street Address City State / Province / Region ZIP / Postal Code Country

Parent email*

Parent Email

Cell Phone (Father)*

Cell Phone (Mother)*

Parents' Home Phone

Daytime/ Work Numbers (Father)

Daytime/Work Numbers (Mother)

If parents are not available in an emergency, notify:

Name/Relationship to Staff*

Phone*

Name/Relationship to Staff*

Phone*

Health History*

Overall good health
Current infectious diseases (if yes, please list)
Physical limitations (if yes, please explain)
Recent illnesses/injuries (if yes, please list)
Chronic/recurring illnesses (if yes, please list)

Health History Continued

Immunization Information:

Have you been fully vaccinated against COVID-19?*

Please scan and upload your COVID-19 vaccination card to your staff account. If you plan to complete your vaccinations after you've submitted this form, please call our office when your vaccines are complete. 616.399.3150

Have you had a tetanus shot in the last 10 years?*

Have you had 2 doses of the MMR Vaccine?*

Have you had the 3 Hepatitis B Immunizations?*

Allergies

Allergies/Non food (please list below)

Food Related Allergies and/or Special Dietary preferences?*

In order to best prepare our kitchen staff for your arrival this summer, it is important we are aware of any food related allergies that will impact your time of employment here. We are committed to accommodating you in this way and helping you to stay healthy.

*In regards to food preferences for reasons other than medically necessary, we wish to offer enough options that can give you the sustenance you need to follow these preferences as much as possible. Please be sure to specify the difference between a preference and a food allergy by selecting the "preference category" rather than the other two categories related to allergies.

For each allergy category, please select the appropriate choice to indicate the severity of your allergy.

Dairy

Gluten

Soy

Egg

Seafood

Shellfish

Peanut

Tree Nuts

Other (please specify)

Are you Vegan?*

Are you Vegetarian?*

Check all that apply:

I eat eggs.
I eat dairy.
I eat fish.

Medical Information

Please list all current prescription drugs or medications

Physician (name/location)*

Physician Phone Number*

Health Insurance Carrier:*

Insurance Policy Number:*

Additional comments

I understand that GENEVA will provide worker's compensation insurance covering any accidents while I am on duty, but that I am responsible for providing my own health insurance and that I will be responsible for all expenses relating to sickness. I also understand that all medications must be kept under lock at the Nurse's quarters. All information provided here has been completed to the best of my knowledge as of the date and my signature below.

Today's Date:*

Signature*