Camp Bethel Adult Participant Health Form
Information from this form will be held confidential by the camp staff and instructors. The intent of this form is to provide the leaders with information needed to provide appropriate emergency care. Save a copy of your completed answers for your records. If needed, submit additional information or descriptions via e-mail to CampBethelOffice@gmail.com. If you have medical insurance or Medicare/Medicaid, bring your card OR bring a scan/image/copy of the front & back of your insurance information.
SCROLL THIS FORM DOWN AS YOU GO, and be sure to click the SUBMIT button at the bottom of the form! Items with a red * asterisk are REQUIRED items.
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Email *
Your LAST name *
Thank you for using correct capitalization for names and titles throughout this health form.
Your FIRST name *
Thank you for using correct capitalization for names and titles throughout this health form.
Dates and Title of Course or Program you are attending. *
As closely as you can, indicate the course/program you are attending.
Year of Birth. *
Example: 1970
City and State of residence. *
Thank you for using correct capitalization and correct state abbreviation.
Your cell phone number or best number to reach you. *
Include area code, (ex: 540-555-1234). This is in case we need to contact you during or prior to your event/time at Camp Bethel.
Emergency Contact Information
In case of emergency who should we contact?
Who to call in case of emergency?
Their cell phone or best phone number:
include area code, (ex: 540-555-1234)
INSURANCE INFORMATION
Camp Bethel provides only limited secondary medical insurance for participants. REQUIRED: Bring your card or bring a scan or image of the front & back of your medical insurance card.
Are you covered by individual/family medical/hospital insurance and/or Medicaid/Medicare?
Clear selection
If we had to take you to the emergency room, which local hospital is your preferred choice?
(ex: Carilion Roanoke Memorial; Lewis Gale Salem; Carilion Montgomery County; etc.)
Allergies and Restrictions
List all known allergies and restrictions, including food allergies, dietary restrictions, and environmental allergies. Describe the severity of any allergies or restrictions. Describe your reaction and the best management of the reaction. Describe the best accommodation of any restrictions. If none, leave blank or write NONE.
Medical History and additional information:
Describe other concerns, conditions, special restrictions, or considerations we should know about in case of emergency.
Have you been ill or exposed to illness recently?
Our goal is to ensure those who feel ill or those who are still recovering from any illness, DO NOT ATTEND.
Participant Authorizations:
I have read and understand the course/program information. I understand that I will be participating in physical activities (including, but not limited to those listed in the course/program descriptions) and the potential for accidents exists. I understand that the camp has established guidelines to minimize risks and provide a safe environment, and that Camp Bethel will implement multiple practices to limit the spread of and exposure to communicable diseases (including COVID-19 and other viruses), and that Camp Bethel is licensed by Virginia to operate a Summer Camp, Dining Hall and Swimming Pool, and that Camp Bethel adheres to over 300 operational and safety standards. In consideration of acceptance to Camp Bethel,
I indemnify and hold harmless Camp Bethel, the Virlina District Board–Church of the Brethren, Inc. and its staff, volunteers and officers from any and all liability, claims, damage, injury or illness sustained by me, and
I verify that the information on this Health Form is correct and complete as far as I know.  This form may be copied for camp records, and
I hereby give permission to the camp to provide routine health care and seek emergency medical treatment.  I agree to the release of any records necessary for emergency purposes. I give permission to the camp to arrange necessary emergency medical transportation for me. In the event I cannot communicate in an emergency, I hereby give permission to the physician selected by the camp to secure and administer treatment for me including ordering x-rays, administering tests, and admittance to a hospital, and
I understand that Camp Bethel provides only limited secondary medical insurance coverage for participants. I will possess proof of primary personal/family medical insurance coverage for me, and
I agree to read all information included in confirmation materials sent to me after registration and to share this information with my emergency contact person, and to read, sign and return any and all applicable forms and waivers, and
I permit photos, video and audio of activities or interviews that may include me to be used in camp/course promotion without liability or remuneration, and
I verify my Physical Assessment as described below. (We encourage participants to consult your family’s primary care physician to assess your current health and physical abilities.  Provide any updates or changes to this information to leaders at check-in.)
I am physically able to participate in activities or instruction as described in the course information (unless specified in "additional information" above).
I verify this information.  (This is a required question.) *
After agreeing (clicking "YES"), be sure to SCROLL THIS FORM DOWN to the SUBMIT button in order to send us this camper Health information!
**To complete this form, click SUBMIT.
If you do not click "Submit" we will not receive your information, so be sure to click SUBMIT.  Thanks!  Once submitted, you will be directed back to the Camp Bethel website.
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