Day Camp Health History Form
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1
2Stevens Point Area YMCA
Child Care/Day Camp – Health History and Care Form
FULLY COMPLETE ALL SECTIONS of this REQUIRED Health and Care Form and return to:
Stevens Point Area YMCA, Child Development Office, 1000 Division Street, Stevens Point, WI 54481 (715) 342-2999
First Day of Attendance: ______________________
Participant Name __________________________________________________________
M F
Birth Date _____________
Age ________
Street Address ________________________________________________________________________________________________________________________________
Street
City
State
Zip
Home Phone ___________________________
School ____________________________ Grade_________
Height ________ Weight________
Parent/Guardian Name _______________________________________
Parent/Guardian Name___________________________________________
Home Address ___________________________________________________
Home Address ______________________________________________________
City _________________________
State __________ Zip ___________
City _____________________________
State __________ Zip _________
Workplace Name, Address & Ph. # __________________________
Workplace Name, Address & Ph. # _____________________________
______________________________________________________________________
_________________________________________________________________________
Day/Cell Ph._____________________
Home Ph. __________________
Day/Cell Ph._____________________
Home Ph. _____________________
Email ______________________________________________________________
Email __________________________________________________________________
Please Indicate any Custody Issues _____________________________________________________________________________________________________________________
Emergency Contacts (other than Parent/Guardian) and Persons Authorized to Pick Up Child.
Emergency Contact Name ___________________________________
Emergency Contact Name_______________________________________
Relationship to Child ___________________________________________
Relationship to Child ______________________________________________
Home Address ___________________________________________________
Home Address ______________________________________________________
City _________________________
State __________ Zip ___________
City _____________________________
State __________ Zip _________
Workplace Name, Address & Ph. # __________________________
Workplace Name, Address & Ph. # _____________________________
______________________________________________________________________
_________________________________________________________________________
Day/Cell Ph._____________________
Home Ph. __________________
Day/Cell Ph._____________________
Home Ph. _____________________
Participant
Physician _________________________________________________________________________________________________
Phone _______________________
Dr. Name/Facility
Office Address
Participant
Dentist _____________________________________________________________________________________________________
Phone _______________________
Dr. Name/Facility
Office Address
Insurance Information: Is Participant covered by family medical/hospital insurance?
______ YES
_____ NO
Carrier or Plan Name _________________________________________________________________________
Group # _______________________________
Carrier Address & Phone # _________________________________________________________________________________________________________________
Name of Insured ___________________________________________
Relationship to Participant ______________________________________
Emergency Treatment Authorization: In the event I cannot be reached in an emergency, I authorize the YMCA staff to
transport to and/or secure from any licensed hospital, physician and/or medical personnel any emergency care or treatment
deemed necessary for my child. I agree that I will be responsible for the payment of any and all medical services rendered.
Signature of Parent/Guardian _______________________________________________________________________
Date _______________________________
OVER
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