2024 Westfield Area Y SACC/Summer Camp Health History
Camper Name
*
First Name
Middle Name
Last Name
Birthday
*
-
Month
-
Day
Year
Date
Age
*
Sex
*
Address
*
Street Address
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Authorized Pick Up/Emergency Notification Information
P/G 1:
*
First Name
Last Name
Day Phone
*
Please enter a valid phone number.
Cell #
*
Please enter a valid phone number.
Relationship:
*
Pick Up
*
Yes
No
Emergency Contact
*
Yes
No
P/G 2:
First Name
Last Name
Day Phone
Please enter a valid phone number.
Cell #
Please enter a valid phone number.
Relationship:
Pick Up
Yes
No
Emergency Contact
Yes
No
Name:
First Name
Last Name
Day Phone
Please enter a valid phone number.
Cell #
Please enter a valid phone number.
Relationship:
Pick Up
Yes
No
Emergency Contact
Yes
No
Name:
*
First Name
Last Name
Day Phone
*
Please enter a valid phone number.
Cell #
*
Please enter a valid phone number.
Relationship:
*
Pick Up
*
Yes
No
Emergency Contact
*
Yes
No
Name:
First Name
Last Name
Day Phone
Please enter a valid phone number.
Cell #
Please enter a valid phone number.
Relationship:
Pick Up
Yes
No
Emergency Contact
Yes
No
Name of Family Physician
*
Physician Phone Number
*
Please enter a valid phone number.
Name of Dentist/Orthodontist:
*
Dentist Phone Number
*
Please enter a valid phone number.
Immunization History:
Please record the date (month & year) of the basic immunizations and the most recent booster. If you have any questions, check with your doctor. Physician's signature is NOT required. NO SUPPLEMENTAL SHEETS PERMITTED! Dates REQUIRED and must be written on this form.
DPT Booster
Date: Month and Year
Tetanus Booster
Date: Month and Year
Polio OPV (sabin)
Date: Month and Year
MMR
Date: Month and Year
Pertussis
Date: Month and Year
HBV
Date: Month and Year
HIB
Date: Month and Year
Varciella
Date: Month and Year
Tuberculin Test
Date: Month and Year
Result
Date: Month and Year
Health History:
Check-Giving Approximate Dates
Date of Last Medical Examination
-
Month
-
Day
Year
Date
Allergies
Yes or No
Hay Fever
*
Poisoning Ivy/Oak
*
Insect Stings
*
Penicillin
*
Drugs
*
Diseases
Yes or No
Chicken Pox
*
Measles
*
German Measles
*
Mumps
*
Asthma
*
Conditions
Yes or No
Ear Infections
*
Heart Defect/Disease
*
Convulsions
*
Diabetes
*
Bleeding Disorders
*
Food/Medication Allergies (If none, please type none):
*
Will you be sending an asthma inhaler?
*
Will you be sending an Epipen?
*
Operations or Serious Injuries (Dates) (If none, type none):
*
Chronic or Recurring illness including Seizures (If none, type none):
*
List of All Medications that your child is currently taking (If none, type none):
*
Are there any activities your child should NOT participate? (If none, type none)
*
Please describe any current physical, mental or psychological conditions requiring medication, treatment or restrictions (If none, type none):
*
IMPORTANT: PLEASE NOTIFY THE Y IF THIS CHILD HAS BEEN EXPOSED TO ANY COMMUNICABLE DISEASE
HEALTH POLICY
In case of injury, participant's own personal insurance policy will cover medical costs. The YMCA does NOT provide medical insurance
Do you carry family medical insurance?
*
Yes
No
If yes, then Carrier:
Policy Group #
PARENT'S AUTHORIZATION:
This health history form is correct as far as I know, and the person herein described has permission to engage in all prescribed activities except notified by me. The person herein has had a physical examination by his/her doctor within the last year and is in good health to participate in Westfield Area Y programs. I hereby give permission to the physician selected by the Program Director or Coordinator to order X-rays, routine tests and treatment for the health of my child in the event of an emergency. I hereby give permission to the physician selected by the Director or Coordinator to emergency transport, hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for my child as named above in the event of an emergency if I cannot be reached. By my signing below, I agree to the use of electronic signatures.
Signature of Parent or Guardian
*
Date
*
-
Month
-
Day
Year
Date
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