The Ymca General Information, Medical History & Release Forms (Page 3 of 4) in pdf

General Information, Medical History & Release Forms for B.R. Ryall YMCA

Please provide all dates (mm/yy) of immunizations for:

DPT __________ __________ __________ __________ __________ __________

Has the participant had:

Yes

__________ __________ __________ __________

(tetanus/diptheria)

Measles

Tetanus __________ __________ __________ __________ __________ __________

Chicken Pox

Polio __________ __________ __________ __________ __________ __________

German Measles

MMR __________ __________ __________ __________ __________ __________

Mumps

or Measles __________ __________ __________ __________

Hepatitis A

or Mumps __________ __________ __________ __________

Hepatitis B

or Rubella __________ __________ __________ __________

Hepatitis C

Haemophilus Influenza B __________ __________ __________ __________

Hepatitis B __________ __________ __________ __________

Varicella

__________ __________ __________ __________

(chicken pox)

Medications

Please list ALL medications (including over the counter or non-prescription drugs) taken routinely. We encourage parents to administer medications

at home whenever possible.

q Participant takes NO medications on a routine basis

q Participant takes medications as follows:

Medication 1 _____________________________ Dosage/Time of Day ___________________________________ Reason _______________________________________________________________________

Medication 2 _____________________________ Dosage/Time of Day ___________________________________ Reason _______________________________________________________________________

I understand that medications must be brought in their original container and given to the program or site director when my child arrives. In

addition, I understand that all medication must be accompanied with a written note from the prescribing physician. I authorize the B.R. Ryall YMCA

to administer the above medication to my child while he/she is in the YMCA programs.

Parent/Guardian Signature _________________________________________________________________________________________________________________ Date ____________________________________

Insurance Coverage

Is the participant covered by family medical/hospital insurance? q Yes q No Insurance Provider ______________________________________________________________

Name of Primary Insured __________________________________________________________________ Policy # __________________________________ Group # __________________________________

Additional Information

Please provide any additional information about the participant’s behavior and physical, emotional, or mental health about which Program Staff

should be aware.

________________________________________________________________________________________________________________________________________________________________________________________________

During the course of registering for some programs, the YMCA requests pertinent medical information be shared with us in order to serve you and your family

in the safest possible environment. We understand that medical information about you and your child’s health is personal and we are committed to protecting

the information that you share with us.

B.R. RYALL YMCA

| 49 Deicke Dr. | Glen Ellyn, IL 60137 | 630.858.0100 |

of Northwestern DuPage County