Teacher Health History Record

Battle Creek Public Schools Outdoor Education Center, Clear Lake Camp
10160 S M-37 Hwy, Dowling, MI 49050. PH: 269-721-8161. www.clearlakecamp.org

CAMP LICENSING RULES
Part 1. R 400.11125 Staff Requirements
Rule 125. A camp shall maintain a health history statement for each staff member. The statement shall include any physical limitations, current infectious diseases, and any current prescription drugs or medications. A camp shall maintain and safeguard any health information received in accordance with Act No. 368 of the Public Acts of 1978, as amended being 333.1101 et seq. of the Michigan Compiled Laws

Name Name * First Last
Name of School *
Date of Birth Date of Birth / MM / DD YYYY
Name of Personal Physician Name of Personal Physician First Last
Personal Physician Phone Number Personal Physician Phone Number - ### - ### ####
CURRENT HEALTH ISSUES AND HISTORY
List any allergies you have
List any health problems you have including current infectious diseases
List any medications you take regularly include name, frequency and dosage.
Name of Emergency Contact Person Name of Emergency Contact Person First Last
Emergency Contact Phone Number Emergency Contact Phone Number - ### - ### ####
I certify that this information is true to the best of my knowledge.
Draw your signature into the box below. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY

Teacher Health History Record

Teacher Health History Record

CURRENT HEALTH ISSUES AND HISTORY