Ymca Camp Hi-Rock Medical Form For Staff 17 Years And Under printable pdf download

YMCA Camp Hi-Rock Medical Form

For Staff 17 years and under.

Parent or Guardian, please complete front page. This form must be at camp when camper arrives.

Staff Name:_______________________________________________________ Date of Birth:__________________ Age:_________ Gender:_________

Home Address:___________________________________________________ City:_____________________________ State:______ Zip:________________

Mother/Guardian’s Name:___________________________________ Father/Guardian’s Name:________________________________________

Address:_________________________________________________________ Address:_______________________________________________________________

City:______________________________ State:_______ Zip:___________ City:_________________________________ State:________ Zip:____________

Home Phone:(________)__________________________________________ Home Phone:(__________)_____________________________________________

Work Phone: (________)__________________________________________ Work Phone: (__________)_____________________________________________

Name of Emergency Contact other than parent/guardian listed above:___________________________________________________

Home Phone:(_________)_________________________________________ Work Phone:(_________)_______________________________________________

Please keep camp informed of other address and phone numbers where you can be reached

if you will be traveling while you child is at camp.

Health Insurance Information: Please attach a photo copy of insurance card or form.

Does your health insurance company require notification prior to emergency care or appointment with

non-primary care physician? ___________

Medical History: Has this staff member ever required psychiatric counseling? Explain: ____________________________

___________________________________________________________________________________________________________________________________________________

Dates of operations or serious illness: _______________________________________________________________________________________________

Disability or chronic or recurring illness: ___________________________________________________________________________________________

Activities encouraged or limited due to health concerns: ______________________________________________________________________

Dietary modifications: ____________________________________________________________________________________________________________________

Please list allergies to medications: __________________________________________________________________________________________________

Please read, understand, and sign the following release, indemnity, and authorization for treatment.

I consent to the aforementioned staff member participating in any YMCA Camp Hi-Rock programs or activities, either on

or off camp property. I acknowledge that participation in camp activities has inherent risk. I, the undersigned parent

or guardian, assume that risk on behalf of my child and will indemnify and hold harmless the camp/Central Connecticut

Coast YMCA from and against all claims and demands on account of, or in any way from, any accidental occurrence. In

the event that my child should need further medical treatment while at camp, I give the camp medical staff permission

to order x-rays, routine tests, treatments that may require hospitalization, and necessary transportation. I give the

camp medical staff permission to administer medication or treatment prescribed by the camp’s local physician should

this become necessary. I understand that the camp medical staff may be unable to contact me at the time when

medical treatment is necessary and therefore grant permission for them to seek and administer such treatment and

medication prior to contacting me for further permission. I authorize payment of medical benefits to the health care

provider for any necessary services and the release of any medical or other information necessary to process claims for

visits incurred. In addition, I give the camp medical staff permission to administer other over-the-counter medications

they deem necessary. I confirm that, to the best of my knowledge, my child is not allergic to any medications other

than those listed above. I further grant any pictures or video taken of my child at camp may be used for publicity and

promotional purposes. This completed form may be photocopied. I have read the above and understand its meaning.

Printed name of Parent/Guardian ____________________________________________________________________

Signature of Parent/Guardian: ________________________________________________________________________

Date: ____________________

Ymca Camp Hi-Rock Medical Form For Staff 17 Years And Under