New Staff Application - Camp Ba Yo Ca

Personal Information

Name *

Address *

Phone Number *

Email *

Social Security Number *

Parent's Name *

Parent's Phone Number *

Sex *

Age *

Birthday *

School You Attend *

Grade *

Health Information

Tetanus (Booster Recommended every 10 years after initial immunization) *

Polio (1963 oral series sufficient or at least 4 by kindergarten) *

Please List Any Medications to be Taken (This must be administered by the camp nurse while at Camp.) *

Please: 1. Explain any health problems (physical or psychological). 2. Fully explain any other important health related information. 3. List any activity restrictions *

Emergency Contact *

Emergency Contact's Address *

Emergency Contact's Phone Number *