Delaware Family Ymca 2017 Summer Camp Registration Form (Page 3 of 4) in pdf

2017 Summer Camp Registration Form

DELAWARE FAMILY YMCA

2564 Delaware Avenue, Buffalo, NY 14216

P: (716) 875-1283 F: (716) 875-0305

ChILD’S InFoRMAtIon

Name

____________________________________________________________________________________________________

Date of Birth ________________________________________

(first/middle/last)

CAMPER hEALth hIStoRY

The following information must be completed by the parent/guardian. The intent of this information is to provide camp staff the background to

provide appropriate care. Provide complete information so that the camp is aware of your child’s needs.

Child’s Physician______________________________________________________________________________________________________

(p) ____________________________________________________________

Insurance Carrier____________________________________________________________________ Identification # ________________________________________ Group # _______________________

Name of insured _________________________________________________________________________________________

Relationship to child _________________________________________________

Allergies

Describe reaction and management of the reaction

•

Medications (e.g., penicillin)

________________________________________________

________________________________________________________________________________________

•

Food (e.g., eggs, dairy)

________________________________________________

________________________________________________________________________________________

•

Other (e.g., insect stings, hay fever)

________________________________________________

________________________________________________________________________________________

Medications

Medications require a separate form. Please contact the camp director or staff for more information.

Immunization History - Attach a copy of child’s immunization records and list the month/day/year administered below.

DPT Series

/ /

MMR

/ /

Tetanus/Diphtheria

/ /

or measles

/ /

Tetanus

/ /

or mumps

/ /

Polio OPV (Sabin)

/ /

or rubella

/ /

HIB Vaccine

/ /

Varicella

/ /

Hepatitis B

/ /

TB Mantoux Test

/ /

Haemophilus Influenza B

/ /

TB Test Results

[ ] Positive [ ] Negative

Has participant had:

1. Measles

[ ] Yes

[ ] No

15. Recent injury, illness or infectious disease

[ ] Yes

[ ] No

2. Chicken Pox

[ ] Yes

[ ] No

16. Chronic or recurring illness/condition

[ ] Yes

[ ] No

3. German Measles

[ ] Yes

[ ] No

17. Heart defect/disease/murmur

[ ] Yes

[ ] No

4. Mumps

[ ] Yes

[ ] No

18. Eating disorder

[ ] Yes

[ ] No

5. Hepatitis A/B/C

[ ] Yes

[ ] No

19. Diarrhea/constipation

[ ] Yes

[ ] No

6. Mononucleosis

[ ] Yes

[ ] No

20. Wear glasses, contacts or protective eye wear

[ ] Yes

[ ] No

7. Frequent ear infections

[ ] Yes

[ ] No

21. Orthodontic appliance (e.g., retainer)

[ ] Yes

[ ] No

8. Asthma

[ ] Yes

[ ] No

22. Hypertension (high blood pressure)

[ ] Yes

[ ] No

9. Diabetes

[ ] Yes

[ ] No

23. Emotional difficulties for which professional

[ ] Yes

[ ] No

1 0. Seizures/Convulsions

[ ] Yes

[ ] No

help was sought

11. Frequent headaches

[ ] Yes

[ ] No

24. Any specific activities that child cannot

[ ] Yes

[ ] No

1 2. Head Injury

[ ] Yes

[ ] No

participate in or needs assistance

1 3. knocked unconscious

[ ] Yes

[ ] No

25. Dizzy/passed out after physical activity

[ ] Yes

[ ] No

1 4. Skin Problems

[ ] Yes

[ ] No

(e.g., itching rash, acne)

Date of last physical ______________________________________________________________________________

Please explain any “YES” answers, noting the applicable number _____________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________________

Any additional information about the participant’s behavior and physical, emotional or mental health the camp should be aware of:

___________________________________________________________________________________________________________________________________________________________________________________________________

PERMISSIon to PRoVIDE nECESSARY tREAtMEnt oR EMERGEnCY CARE

[ ] Yes [ ] No

I hereby give permission to the medical personnel selected by the camp director to order x-rays, routine tests, treatment;

to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for

me/or my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by

the camp director to secure and administer treatment, including hospitalization, for the participant. This completed form

may be photocopied for trips out of camp.

17DL Camp Reg Form 170124