Form Yl6007 - Camping Health, Consent And Release Form

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CAMPING HEALTH, CONSENT AND RELEASE FORM
FOR AREA DIRECTORS
Area #
Area Name
Information in this document is protected by HIPAA privacy laws and should be handled accordingly.
This form is only good for travel to and from, and attendance at, this specific camp. A new form must be completed
Trip Leader/Area Dir
for each Young Life Camp experience.
School Name
MAKE A COPY FOR YOUR RECORDS. CAMPS MAY NOT FAX OR SEND COPIES TO OTHER CAMPS.
Camp Dates
Note to Parent/Guardian/Guest: Young Life wants the camp experience to be a safe and healthy one.
 Camper  Leader  Assigned Team
However, in the event of an accident or illness, it is important that we have the following information:
 Summer Staff  Work Crew  Adult Guest
1.
Medical history
2.
Medical insurance information
3.
Proof of physical examination, verified by physician’s signature, required for ALL guests attending Beyond Malibu or camps located in CO or MN (Castaway, Crooked Creek,
Frontier Ranch, Quaker Ridge, RMR, Trail West, or Wilderness Ranch).
4.
Pregnant and Post-Delivery Teens: Pregnant teens and teen moms 6 to 12 weeks post-delivery on camp date must have a physician’s release. Teen moms less than 6 weeks
post-delivery on camp date may not attend. Pregnant teens over 34 weeks are not allowed to attend camp. Pregnant teens over 30 weeks may not attend Washington
Family Ranch, Beyond Malibu, Wilderness Ranch, or remote rental camps.
Name
Birthdate
Gender
Male
Female Age
Last
First
Middle Initial
Parent/Guardian/Spouse
Email
Cell Phone
(
)
Home Address
Home Phone (
)
Street Address
City
State/Province
Zip
Second Parent/Guardian
Email
Cell Phone
(
)
Home Address
Home Phone (
)
Street Address
City
State/Province
Zip
If not available in an emergency, notify:
Cell Phone
(
)
Home Address
Home Phone (
)
Street Address
City
State/Province
Zip
ACCIDENT COVERAGE
I understand that my personal insurance will be primary coverage for camper accidents and that Young Life’s insurance is secondary up to a maximum of $20,000 ($4,000
for dental claims). Exception: If the total claim is less than $250, Young Life will pay the full amount. On claims above $250, Young Life will coordinate payments for
deductibles and co-pays. Young Life’s policy does not cover camper illnesses. If you have questions, please contact Young Life Benefits and Insurance at (719) 381-1950.
 My insurance company
Policy Number
Insurance company address
 Not currently insured – Young Life reserves the right to subrogation if it is later determined that personal medical insurance was in place.
Health Care Recommendations: This section must be completed by a physician, nurse practitioner, or physician’s assistant for all individuals attending
Beyond Malibu; all individuals attending camps located in CO or MN; or for a teen attending any Young Life camp who is pregnant or has given birth within 12
weeks of the camp date. Parent or adult applicant must complete this section if these conditions do not apply.
1.
Does applicant have a medical condition such as sickle cell or respiratory or other ailment or condition which would prevent participation at camps with an
altitude of 7–14,000 feet?  Yes  No
If yes, describe condition:
Street Address
City
State/Province
Zip/Postal
2.
Does the applicant have a medical condition which would prevent participation in an active camp program?  Yes  No
If yes, describe condition:
3.
The applicant is authorized to carry an inhaler, epi pen and other emergency medications with them at all times?  Yes  No
PHYSICIAN’S SIGNATURE (CO, MN, Beyond Malibu, pregnant/post-delivery teens)
 I have examined the applicant within the past 12 months.
Date examined
Height
Weight
Blood Pressure
Physician Signature
Date
Print Name
May be signed by Physician, Nurse Practitioner, or Physician’s Assistant
(
)
Address
Phone
The applicant is currently under the care of a physician for the following condition(s)
Chronic or recurring illness or medical condition (including behavioral conditions); operations or serious injuries (dates)
Explanation of any reported loss of consciousness, convulsion or concussion
Any medically-prescribed meal plan or dietary restrictions
Any camp activities from which applicant should be excluded
YL6007 (Mar 2013)

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