YMCA Camp Lake Helena Camper Information

YMCA CAMP LAKE HELENA
THE INFORMATION ON THIS FORM HELPS YMCA CAMP LAKE HELENA STAFF PROVIDE THE BEST CARE FOROFFICE USE ONLY: YOUR CHILD. WITHHOLDING, MISREPRESENTING, OR INCOMPLETE INFORMATION MAY BE GROUNDS FOR DISMISSAL. PLEASE NOTIFY YMCA CAMP LAKE HELENA STAFF IF THERE ARE ANY CHANGES TO THIS FORM.

A MEDICAL EXAM IS REQUIRED ONLY IF THE CAMPER HAS HAD SURGERY, A SERIOUS ILLNESS, AN INJURY THAT HAS LIMITED HIS/HER/THEIR ACTIVITY, OR HAS BEEN HOSPITALIZED IN THE PAST YEAR.

THIS FORM IS FOR YMCA CAMP LAKE HELENA HEALTH CENTER USE ONLY.
Name

FIRST NAMEMIDDLE INITIALLAST NAME
Address

HOME ADDRESS

Street Address Line 2

CITYSTATE

ZIP
Gender
BIRTHDATE

MonthDayYear
Date
AGE AT START OF CAMP
GRADE ENTERING IN THE FALL
FIRST PARENTSGUARDIANS FULL NAME
CELL PHONE
Format: (000) 000-0000.
WORK PHONE
Format: (000) 000-0000.
SECOND PARENTSGUARDIANS FULL NAME
CELL PHONE
Please enter a valid phone number.Format: (000) 000-0000.
WORK PHONE
Please enter a valid phone number.Format: (000) 000-0000.
CAMPER LIVES WITH

Other
EMERGANCY CONTACT AND AUTHORIZED PICK UP
THE BELOW-NAMED ADULTS LISTED ON THIS FORM UNDERSTAND THEY HAVE BEEN IDENTIFIED AS CONTACTS WHILE THE CAMPER IS IN THE CARE OF YMCA CAMP LAKE HELENA, AND THAT THEYMAY BECONTACTEDTOPICKUP THECAMPERAS NEEDED, DUE TO ILLNESS, INJURY, AND/OR BEHAVIOR, OR AT THE END OF THE REGISTERED SESSION. ONLY AUTHORIZED ADULTS LISTED ON THIS RELEASE CAN PICK UP CAMPERS FROM YMCA CAMP LAKE HELENA. FOR YOUR CAMPER'S SAFETY, PHOTO IDENTIFICATION WILL BE REQUIRED AT PICK UP.

IF YOU NEED TO MAKE ANY CHANGES TO THIS FORM, PLEASE NOTIFY YMCA CAMP LAKE HELENA AT CAMPLAKEHELENA@YMCAPKC.ORG IMMEDIATELY. WORK PHONE
FIRST AND LAST NAME
Relationship to the camper
PHONE
Format: (000) 000-0000.
FIRST AND LAST NAME
Relationship to the camper
PHONE
Format: (000) 000-0000.
FIRST AND LAST NAME
Relationship to the camper
PHONE
Format: (000) 000-0000.
FIRST AND LAST NAME
Relationship to the camper
PHONE
Format: (000) 000-0000.
INSURANCE INFORMATION
CARRIER/PLAN NAME
GROUP NO
INSURANCE ID NO
NAME OF INSURED
RELATIONSHIP TO CAMPER
HEATH HISTORY: PLEASE CHECK ALL THAT APPLY

Ever been hospitalized? Ever had surgery? Have recurrent/chronic illnesses? Had a recent infectious disease? Had a recent injury? Had asthma/wheezing/shortness of breath? Have diabetes?

Wear glasses, contacts, or protective eyewear? Had fainting or dizziness? Passed out/had chest pain during exercise? Had mononucleosis "mono" during the past 12 months? If female, have problems with periods/menstruation? Ever had back/joint problems? Have problems with diarrhea/constipation? Have any skin problems? Traveled outside the country in the past 9 months?
HAS/DOES YOUR CHILD:
EXPLAIN ANY CHECKED ANSWERS ABOVE

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ALLERGIES MEDICATION, FOOD, ETC
REACTION AND MANAGEMENT OF REACTION
IMMUNIZATIONS (REQUIRED)

IMMUNIZATIONS INDICATE THE MONTH AND YEAR OF THE LAST IMMUNIZATION/BOOSTER
TETANUS
MEASLESMUMPSRUBELLA
HEPATITIS A
DIPHTHERIAPERTUSSIS DtaPDT
CHICKEN POX
MENINGITIS
HEPATITIS B
MEDICATIONS
PLEASE LIST ALL MEDICATIONS BROUGHT TO YMCA CAMP LAKE HELENA (ATTACH ADDITIONAL PAPER AS NECESSARY KEEP MEDICATIONS IN THEIR ORIGINAL PACKAGING - ORIGINAL PACKAGING FOR PRESCRIPTION MEDICATION MUST IDENTIFY THE PRESCRIBING PHYSICIAN, MEDICATION NAME, DOSAGE, AND FREQUENCY OF ADMINISTRATION. PLEASE CALL IN ADVANCE IF A MEDICATION OR DOSAGE HAS CHANGED IN THE PAST THREE MONTHS.
NAME OF MEDICATION NO 1
REASON FOR TAKING
SIDE EFFECTS
TIME
DOSAGE 1
TIME
DOSAGE 2
TIME
DOSAGE 3
TIME
DOSAGE 4
NAME OF MEDICATION NO 2
REASON FOR TAKING
SIDE EFFECTS
TIME
DOSAGE 1
TIME
DOSAGE 2
TIME
DOSAGE 3
TIME
DOSAGE 4
PLEASE PROVIDE ANY ADDITIONAL INFORMATION ABOUT YOUR CAMPER SUCH AS THEIR GENERAL BEHAVIOR THEIR PHYSICAL EMOTIONAL OR MENTAL HEALTH ANY SIGNIFICANT LIFE EVENTS THAT MIGHT AFFECT BEHAVIOR ANDOR DIETARYOTHER RESTRICTIONS

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MEDICAL TREATMENT AT YMCA CAMP LAKE HELENA

UNDER THE RECOMMENDATION OF CAMP'S OVERSEEING PHYSICIAN AND THE SEASONAL HEALTHCARE DIRECTOR, THE BELOW- LISTED OVER-THE-COUNTER MEDICATIONS MAY BE USED.
PLEASE CHECK ANY PRODUCTS YOU DO NOT WANT ADMINISTERED:
AUTHORIZATION TO PROVIDE NECESSARY TREATMENT OR EMERGENCY CARE
BY MY SIGNATURE, BELOW, I HEREBY GIVE THESE PERMISSIONS TO MEDICAL PERSONNEL SELECTED BY THE CAMP DIRECTOR: ORDER X RAYS, ROUTINE TESTS, OR OTHER TREATMENT; RELEASE ANY RECORDS NECESSARY FOR INSURANCE PURPOSES; RELEASE A DIAGNOSIS AND PRESCRIPTION TO CAMP STAFF; AND/OR PROVIDE/ARRANGE ANY RELATED TRANSPORTATION NECESSARY FOR MY CHILD. IF I AM UNREACHABLE, I HEREBY GIVE PERMISSION TO THE PHYSICIAN SELECTED BY THE CAMP DIRECTOR TO SECURE AND ADMINISTER TREATMENT, INCLUDING HOSPITALIZATION. THIS COMPLETED FORM MAY BE PHOTOCOPIED FOR TRIPS OUT OF CAMP. BOTH SIDES OF THIS FORM ARE CORRECT AND COMPLETE TO BE BEST OF MY KNOWLEDGE, AND THE CAMPER HEREIN DESCRIBED HAS PERMISSION TO ENGAGE IN ALL CAMP ACTIVITIES, EXCEPT AS MAY BE NOTED ON THIS FORM. PARENT/GUARDIAN SIGNATURE*
PARENT/GUARDIAN SIGNATURE
DATE MMDDYYYY

MonthDayYear
Date
PLEASE PRINT NAME
Should be Empty:

IMMUNIZATIONS (REQUIRED)

MEDICAL TREATMENT AT YMCA CAMP LAKE HELENA