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(September 1 - May 31)

SUMMER (June 1 - August 31)
302 Main Street, Milburn, NJ 07041 700 Churchill Street, Pittsfield, MA 01201 TO BE COMPLETED BY LICENSED PHYSICIAN
To Physicians and Their Staff: This person is an employee at Camp Winadu in Pittsfield, Massachusetts. The job includes
physical activity and requires the individual to be outside in a variety of weather conditions. Our healthcare staff and the employee’s work supervisor use the information provided on this form to guide their interface with the employee. The employee can provide their job’s description and list of essential functions to you. If you question the person’s suitability for their job, please talk with them about your concerns and develop a plan to address that concern. You can also speak to one of our camp professionals by calling (914) 437-7200. Thank you!
NAME OF STAFF MEMBER: _______________________________________________________________ Date of Birth: _______________
1. List the chronic health problems of this employee: □ None □ Asthma □ Diabetes □ Allergies □ Other: _________________________ 2. List the prescription medication(s) this person wil take while at camp; provide a medical order for administration. □ None needed while at camp. a. ____________________________________________________________________________________________________________________ b. ____________________________________________________________________________________________________________________ c. ____________________________________________________________________________________________________________________ 3. List the al ergies (food, medication, etc ) of this person . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . □ No known allergies a. __________________________________________________________________________________________ □ Intolerance □ Anaphylaxis b. __________________________________________________________________________________________ □ Intolerance □ Anaphylaxis c. __________________________________________________________________________________________ □ Intolerance □ Anaphylaxis Note: Our expectation is that the employee wil have an EpiPen and know how to use it if anaphylaxis is part of the individual’s health profile. 4. Describe other treatments needed by this person to do their job . . . . . . . . . . . . . . . . . . . . . . . . . . . . . □ None needed _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ 5. Describe any significant physical findings regarding this person and/or describe any limitations that may impact the employee’s job performance. □ No significant findings. ___________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ 6. I examined this individual on _____________. (Exam is required within 24 months of camp attendance) BP_____________ Weight_____________ Height_____________ Date Completed_____________ 7. We may have neglected to ask about something you feel is needed to adequately address this person’s health needs. If so, please add your comments below. □ No additional comments needed. ____________________________________________________________________________ ________________________________________________________________________________________________________________________ These medications are stocked in our camp’s Health Center and wil be used to manage il ness and/or injury of this employee.
Please check those that are contraindicated for this person.

□ Tylenol □ Motrin □ Pepto Bismal □ Tums □ Immodium AD □ Calamine Lotion □ Rhuli Gel □ Tinactin □ Solarcaine □ Benadryl □ Sudafed □ Dramamine □ Lactaid By signing this form, you are telling us that, in your opinion, this person is both physically and emotionally ready to participate as an employee at our camp except as noted in your comments. Name of Licensed Physician: ________________________________________________ Signature: __________________________________________ Title:_____
Office Address: _________________________________________________ City: __________________________________________ State:________ Zip:___________ Telephone Number: ________________________________________________________________________ Date: __________________________________________

Source: http://www.campwinadu.com/WNDU%20Staff%20Medical%20Form%20ACA.pdf

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