Staff Emergency Contacts

Staff Emergency Contact

Sons of Norway District Six Language and Heritage Camps

"*" indicates required fields

Applicant Name*
A copy of this completed form will be sent to this email address.
MM slash DD slash YYYY
Emergency Contacts*
Name
Phone
Relationship
 
Please provide one or more emergency contacts. Click on the "+" to add additional contact rows.
Prescription medications*
Medication
Amount
Frequency
 
Enter "None" in the Medication field if you take no prescription medications. Please use the "+" at the right side to add rows for additional medications.

List all known allergies:

Medication allergies*
Name of Medication:
Describe reaction and management of the reaction.
 
Enter "None" if you have no know medical allergies or wish not respond to this question. Click on the "+" to add additional medications.
Food allergies*
Food name:
Describe reaction and management of the reaction:
 
Enter "None" if you have no know food allergies. Click on the "+" to add additional foods.
Other allergies*
Type of allergy:
Describe reaction and management of the reaction.
 
Include insect stings, hay fever, asthma, animal dander, poison oak/ivy etc. Enter "None" if you have no know allergies. Click on the "+" to add additional items.
MM slash DD slash YYYY
List second date if two-shot series or last buster.
I give permission to the Sons of Norway District Six Language/Heritage Camp to seek medical evaluation and authorize emergency medical treatment if I am unable to give permission.
Sign here using mouse or digital pen.
MM slash DD slash YYYY