Camp Tecumseh Ymca Health Form printable pdf download

CAMP TECUMSEH YMCA HEALTH FORM

CAMP DATES (List

d ates for each week)

This form must be completely filled out and returned to Camp Tecumseh YMCA, 12635 West Tecumseh Bend Road, Brookston, IN 47923,

at least 30 days prior to the start of your camp session. Fax (765-564-3210) Upload completed form at

A copy of camper’s health insurance card should also be attached. Please make all non-emergency calls to camp only between regular office hours

8:00 a.m. – 5:00 p.m. (Eastern Time), Monday – Friday. Thank-you very much!

Sex:

Age:

Name: ____________________________________________________________________

M F

____ Birth Date: ___/____/______

Last

First

Middle Initial

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Mother/Guardian #1:

Home Phone:

(

)

Home Address:

Street & Number

City

State

Zip Code

Work Phone:

(

)

Cell Phone:

(

)

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Father/Guardian #2:

Home Phone:

(

)

Home Address:

Street & Number

City

State

Zip Code

Work Phone:

(

)

Cell Phone:

(

)

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If neither of the above are available in an emergency, please notify:

Alternate Contact #1:

Home Phone:

(

)

Name

Work Phone:

(

)

Cell Phone:

(

)

Alternate Contact #2:

Home Phone:

(

)

Name

Work Phone:

(

)

Cell Phone:

(

)

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Name of Dentist/Orthodontist:

Phone:

(

)

Name of Family Physician:

Phone:

(

)

If yes, Policy Holder’s Name:

Do you have family medical/hospital insurance?

Employer through which insurance is obtained:

Carrier:

Policy or Group #:

If yes, Policy Holder’s Name:

Do you have family prescription drug insurance?

Carrier:

Policy or Group #:

IMPORTANT - MUST BE COMPLETED FOR ATTENDANCE

Parent’s Authorization: This health history is correct so far as I know, and the person herein described has permission to engage in all camp activities,

except as noted by me and/or the examining physician. I understand there is some inherent risk in activities at camp and accidents sometimes occur. I

understand that the camp fee does not include accident insurance. I agree to the release of any records necessary for treatment, referral, billing, or

insurance purposes. I hereby give permission to the physician selected by the camp director to order x-rays, routine tests and treatment for the health of

my child, and in the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to hospitalize,

secure proper treatment for and to order injection and/or anesthesia and/or surgery for my child as named above. I agree that after a place is reserved he

or she will remain until the end of the period unless necessary to withdraw due to illness as defined by the camp physician. I understand that no refunds

are given if a child leaves early because of homesickness or for disruptive behavior as decided by the camp director. I give permission for Camp

Tecumseh to use photos or videos of my child in promotional literature.

I understand that if my child has special health issues I must call the camp at least 90 days in advance of the camper’s stay to determine if the camp can

provide the level of health care needed by my child. I understand that YMCA Camp Tecumseh is not a healthcare facility and may not be able to

reasonably care for my child’s special needs. Health conditions requiring advance clearance include, but may not be limited to:

 Insulin Dependent Diabetes

 Cardiac Situations

 Asthmatics

 Seizure Disorders

 Autism

 Serious Food Allergies

I understand that a fully completed health form, signed by a physician, is required by my child’s first day of camp. For every day these fully completed

forms are not in camp, a fee of $50 per day will be assessed. (Please make yourself a copy of completed forms before mailing to Camp.)

Parent/Guardian Signature:

Date:

PLEASE INCLUDE A COPY OF CAMPER’S HEALTH INSURANCE CARD

IMPORTANT: Please notify the camp if this camper is exposed to any communicable disease during the

three weeks prior to camp attendance, or if camper has been seen by a physician for any reason during this period.