2024 SSA Camp Staff Health Form

Full Name(Required)

First Middle Last

Nickname/Preferred first name(Required)

Date of Birth(Required)

Gender(Required)

Pronouns(Required)

T-shirt size(Required)

Allergies(Required)

Please list your food, drug, or environmental allergies, if any. Type 'none' if none.

Are you a vegetarian?(Required)

Are you a vegan?(Required)

Do you have any other dietary restrictions?(Required)

Medications

Please list any of your medications you would like SSA to know about (emergency purposes). You are not required to share this info.

Emergency Contact

Emergency Contact Name(Required)

First Last

Relationship to staff member:(Required)

Emergency Contact Phone #1(Required)

Emergency Contact Phone #2

Emergency Contact Email(Required)

Authorizations

Please electronically sign each authorization by typing your full name in each prompt.

Photo/Video Release, please type full name:(Required)

I hereby authorize the use of any photos or video taken during SSA Camp to be used for advertising purposes in posters, brochures, promotional videos, and social media.

Health Information Signature, please type full name:(Required)

I certify that the health information in this form is true to the best of my knowledge.

Health Care Authorization Statement, please type full name:(Required)

I hereby give my permission to Superior String Alliance to provide routine, nonsurgical medical care, and to secure emergency medical, surgical, and dental treatment for me in the event of an emergency while she/he/they is/are attending SSA Camp.