Ymca Storer Camps - Oee Youth Health Form
ADVERTISEMENT
1
2
3YMCA STORER CAMPS ~ OEE YOUTH HEALTH FORM
Personal Information
Student’s Last Name (Printed)
Student’s First Name (Printed)
M.I.
Street Address
Date of Birth (Month, Day, Year)
Age
School
Gender
! Male ! Female
City
State
Zip
Height
Weight
Emergency Contact Information
We will certainly call in an emergency, but we’ll also call if we have questions about your camper’s health.
Father/Guardian Name
Father/Guardian Home Phone
Father/Guardian Work Phone
Father/Guardian Cell/Pager
Mother/Guardian Name
Mother/Guardian Home Phone
Mother/Guardian Work Phone
Mother/Guardian Cell/Pager
Emergency Contact Name
Emergency Contact Phone
Relationship to Child
Emergency Contact Cell/Pager
If we cannot reach you or your emergency contact, please provide contact information for other people who know your camper and with whom we can
consult. We assume you have spoken to these contacts and they are willing to assist should the need arise.
Alternate Contact ___________________________________ Phone: ___________________________ Relationship: __________________________
Alternate Contact ___________________________________ Phone: ___________________________ Relationship: __________________________
Medication Information
Please list any additional medications on a separate sheet and attach to your health form.
“Medication” is any substance a person takes to maintain and/or improve his/her health. Includes vitamins and homeopathic remedies.
"
This student will not take any daily medication while attending YMCA Storer Camps.
"
This student will take the following daily medication(s) while attending YMCA Storer Camps. Bring enough of each
medication to last their entire stay. ALL medications must arrive in appropriately labeled pharmacy containers as
described in the “Health Services Parent Information”.
NAME OF MEDICATION
REASON FOR TAKING IT
WHEN GIVEN AND DOSAGE
DATE STARTED
"
Breakfast Dose: ____________________
"
Lunch Dose:________________________
"
Dinner Dose: ______________________
"
Bedtime Dose: _____________________
"
Other: _____________________________
"
Breakfast Dose: ____________________
"
Lunch Dose:________________________
"
Dinner Dose: ______________________
"
Bedtime Dose: _____________________
"
Other: _____________________________
"
Breakfast Dose: ____________________
"
Lunch Dose:________________________
"
Dinner Dose: ______________________
"
Bedtime Dose: _____________________
"
Other: _____________________________
We have many over the counter medications stocked in our Health Centers used to manage illness and injury as directed by our medical protocols.
NOT
Please list any over the counter medications that your student should
be given.
___________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________
Page 1 of 3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical