Ymca Camp Hi-Rock Medical Form For Staff 18 Years And Older (Page 2 of 2) in pdf

Name: __________________________________________________ DOB: ____________________________

Medical History

To be completed by a Physician. A Certificate of Immunization is to be attached. This form

must be fully completed before sending to camp. This is the only form approved by the local Board of Health. It meets

local regulation requirements.

Vaccine

date #1

date #2

date #3

date #4

date #5

date #6

MMR (measles, mumps, rubella)

DTP (diptheria, tetanus, pertussis)

Td/Tdap (if more than ten years have

lapsed since last DTP)

Other: ____________________________

Please list any allergies including reaction and treatment (drug, food and environmental): ________________________

__________________________________________________________________________________________________________________________________________________

Please specify any dietary restrictions: ____________________________________________________________________________________________

Current medications (YOU MUST COMPLETE THE MEDICATION ADMINISTRATION RELEASE FORM): ___________

___________________________________________________________________________________________________________________________________________________

Medical history/conditions that may affect the camper’s activities while at camp: _____________________________________

___________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Activities encouraged or limited by physician: ____________________________________________________________________________________

TB: In high-risk group?

High: PPD date: ________________ Result: __________________

Low

Physician’s Examination: Blood Pressure: _______/________ Pulse: ____________ Height: _____________ Weight: ____________

Physical Development: ___________________________________________________________________________________________________________________

I have completed the above and have examined the individual. In my opinion, the condition of the person

listed above does not preclude his/her participation in an active camp program. I have screened the

individual for active signs of tuberculosis.

Licensed Physician’s Signature: ___________________________________________________________________________Date: ____________________

Address: ____________________________________________________________________________________________Phone: (______)________________________

Please note: According to Commonwealth of Massachusetts Law, we may not admit any child to camp without this

completed medical form. The front page must be completed by the camper’s parent/guardian including the signed

authorization for treatment. This side must be completed by a physician. The camper must have been examined by a

physician within 24 months prior to his/her stay at camp. All campers must have a record of immunizations meeting the

Massachusetts immunization requirements for children attending recreational camps. For more information, please

contact your physician or the camp office.

Ymca Camp Hi-Rock Medical Form For Staff 18 Years And Older Page 2