Enrollment Checklist - Fee Based Ymca Of Silicon Valle (Page 6 of 12) in pdf

YMCA CONFIDENTIAL HEALTH HISTORY AND CONSENT FORM

You must submit a registration form and this health history form together to complete your registration. Copies of

immunization records are required for children under 18 years of age.

Child’s Name: First:

Last:

Address:

City/State/Zip:

Home Phone:

Birthdate:

Grade (in the Fall of this year):

Height:

Weight:

Hair Color:

Eye Color:

Birthmarks/scars:

 Caucasian

 Asian/Pacific Islander

 Hispanic

 African American

 Native American

 Other

T-shirt Size:

 Youth S  Youth M  Youth L  Youth XL  Adult S  Adult M  Adult L  Adult XL  Adult XXL

Parent/Guardian 1: Name:

Address:

Home Phone:

Cell Phone:

E-mail:

Employer:

Work Phone:

Parent/Guardian 2: Name:

Address:

Home Phone:

Cell Phone:

E-mail:

Employer:

Work Phone:

EMERGENCY CONTACTS WITH PERSONS AUTHORIZED TO PICK UP CHILD

In the case of an emergency, we will always contact the parent/guardian first. In the event a parent/guardian cannot be reached, we will contact other friends/relatives. No adults

other than the parent/guardian or people listed below can pick up your child from our program without a legibly written, dated and signed note from the parent/guardian. The person

picking up your child must be at least 16 years old. Picture ID required for pick-up.

Name:

Cell Phone:

Alternate #:

Relationship:

Name:

Cell Phone:

Alternate #:

Relationship:

Name:

Cell Phone:

Alternate #:

Relationship:

Name:

Cell Phone:

Alternate #:

Relationship:

MEDICAL CAREGIVERS (INFORMATION REQUIRED BY STATE LAW)

Family Physician:

Preferred Hospital:

Doctor’s Phone:

Doctor’s Address:

Family Dentist:

Dentist’s Phone:

Dentist’s Address:

Medical Insurance Company:

Policy #:

Immunization History* (include dates): Tetanus Booster:

Tuberculin (TB) Test:

MMR:

DPT:

If you do not immunize your child, please sign here:

If you do not have medical insurance for your child, please sign here:

For preschool participants, a copy of your child’s current immunization record is required.

MEDICAL HISTORY

 Asthma

 Head Lice

 Seizures

 Diabetes

 ADD/ADHD

 Measles

 Sleepwalking

 Tuberculosis

 Chicken Pox

 German Measles

 Ear Infection

 Heart Defect/Disease

 Bleeding/Clotting Disorder

Allergies:  Pollen

 Penicillin

 Poison Oak

 Bee Stings

 Bee Sting Kit

 Foods

 Hay Fever

 Other Insect Stings

 Other Drugs

 Other Allergies?

List Other Allergies Here:

List Dietary Restrictions Here:

Any reason to restrict strenuous activity such as swimming, long hikes, strenuous games, roller coaster rides?

 YES

 NO

If yes, please explain:

List operations, serious injuries or restriction on physical activity:

List current medications and purpose:

Medication Disbursement Authorization:

If your child is currently taking medications, complete this section. This includes over-the-counter and prescription

medications. For your child’s protection, our staff cannot administer medication without this form. Any medicines that you give us for your child must be in the original container with

dosage directions and/or doctor’s instructions clearly labeled. Medication will be administered and documented according to directions on the bottle or by a doctor’s instructions.

Medical Condition:

Medication:

Amount to be given:

When:

Comments or Instructions:

Parent/Guardian Signature:

Date: