2022 Counselor Personnel Form

  • At the end of this form, there is a space for you to upload a copy of your COVID-19 vaccination card, driver's license & insurance card.

    It is strongly preferred that you submit this all at once, but if you need to submit a copy of your vaccination record/license/insurance card at a later time, copy and paste this link for future reference so you can upload it later: https://www.biav.net/counselor-upload-center
  • Emergency Contact Information

  • Individual Needs

  • *If you received J&J as your primary COVID-19 vaccine series, enter N/A.
  • Consent

    In the event of an emergency, I hereby give permission to the camp Medical Director, Dr. Nathan Zasler, or a physician so designated by him, to evaluate and/or treat (including ordering any medically necessary measures such as imaging studies, medications, anesthesia or surgery). I understand that Dr. Zasler’s services are provided at no cost as he volunteers as the camp Medical Director; however, in an emergency situation, other providers will be billing for their services. In a situation where my emergency contact cannot be reached and Dr. Zasler must make emergency medical decisions, I agree to hold him harmless of any damages unless there is gross negligence on his part as the camp Medical Director. By way of this consent, I also give permission for any of the aforementioned clinicians to access information from my treating physician(s). My electronic signature below acknowledges my understanding of the above and agreement to same.
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  • Max. file size: 512 MB.
    You can upload a copy of your COVID-19 card, driver's license & medical insurance card here if you have it ready. To upload this document later, go to https://www.biav.net/counselor-upload-center/.