Ymca Camp Hi-Rock Medical Form For Staff 18 Years And Older printable pdf download

YMCA Camp Hi-Rock Medical Form

For Staff 18 years and older

Please complete this form prior to beginning work.

Name: ________________________________________________________________Date of Birth: __________________Age: ________Gender: ________

Home Address: ______________________________________________________________________________City: ________________________________________

State: ________________________________________________________________Country: ____________________________Zip: __________________________

Emergency Contact: Name: ___________________________________________________________Relation: _________________________________

Home Phone: (_______)________________________________________Work/Cell Phone: (_______)______________________________________________

Primary Care Physician’s Name: ______________________________________________________ Phone: (______)_________________________

Address: ______________________________________________________City: _______________________________State: __________Zip: ________________

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? ___________

Dates of operations or serious illness: ________________________________________________________________________________________________

Disability or chronic or recurring illness: _____________________________________________________________________________________________

Do you have any allergies Y / N; If yes please list with reaction: ____________________________________________________________

_____________________________________________________________________________________________________________________________________________________

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 Staff Member ____________________________________________________________________

Signature of Staff Member: ________________________________________________________________________

Date: ____________________

Ymca Camp Hi-Rock Medical Form For Staff 18 Years And Older