Ymca Storer Camps - Oee Youth Health Form Page 2
ADVERTISEMENT
1
2
3Student Name:________________________________________________
School:_______________________________________________________
Insurance Information
Immunizations
All my student’s immunizations are up to date. " Yes
" No
YMCA Storer Camps does NOT carry health/accident insurance for
campers, schools, and conference camping participants.
Date of last Tetanus Booster: Month/Year_____________________
Allergies
Nutrition
#
This student has no known allergies.
Our kitchen prepares well-balanced meals. We can work with some
medically prescribed diets but do not cater to individual food
#
Is allergic to this food(s): _______________________________
preferences.
________________________________________________________
#
This student eats a regular diet.
" No " Yes: Ingestion!
Causes anaphylaxis?
#
This student has the following type of diet.
" Yes: Contact! " Yes: Airborne!
" Semi-vegetarian (no pork or beef)
Describe their reaction and how it is managed:
_______________________________________________________
" Pesco (no pork, beef or chicken)
__________________________________
___________________________________________________________________________________
" Lacto-ovo (no pork, beef, chicken, seafood or fish)
___________________________________________________________________________________
" Vegan (no meats, seafood, eggs or dairy)
#
Is allergic to this medication: ___________________________
#
#
This student does not eat pork because of faith reasons.
Causes anaphylaxis? " No
" Yes!
#
This student is gluten-intolerant.
Describe their reaction and how it is managed:
_______________________________________________________
#
This student is lactose-intolerant.
__________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Please provide any additional information if necessary:
#
Is allergic to the following: ____________________________
____________________________________________________________________________________________
#
____________________________________________________________________________________________
Causes anaphylaxis? " No
" Yes!
____________________________________________________________
Describe the reaction and how it is managed:
Please call us at 517-536-8607 if you have questions pertaining to
_______________________________________________________
__________________________________
your student’s dietary needs.
__________________________________________________________________________________
___________________________________________________________________________________
Health History
Please check those that pertain to your camper and describe how it is handled at home.
#
My camper is free from illness, injury, physical challenges or health concerns that would affect participation in programming.
!Asthma, Diabetes or Anaphylaxis
The following is TRUE for my camper:
" Anaphylaxis !
Please complete the additional “Request for Information”
forms and attach to this Health Form. Forms can be
" Asthma !
downloaded from our website:
" Diabetes !
" ADD/ADHD
" Autism
" Has Glasses/Contacts
" Bedwetting
" Had Chicken Pox/Varicella Immunization
" GIRLS ONLY: Knows about menstruation
" Bleeding/Clotting
" Hearing Impairment
and/or has regular menstrual history
" Chronic Illness
" Head Injury
" GIRLS ONLY: Menstrual cramps
" Diarrhea/Constipation
" Heart Defect/Disease
" Eating Disorder
" Homesickness
" Recent Illness:_______________________________
" Emotional Health Concern
" Psychiatric Treatment/Counseling
" Recent Injury:________________________________
" Fainting
" Seizure Disorder
" Recent Hospitalization:_______________________
" Frequent Colds
" Sleepwalking
" Recent Surgery:______________________________
" Frequent Ear Infection
" Skin Problems
" Other (specify):______________________________
" Frequent Headaches
" Surgical History of Consequence
Please give more information about checked items above. Attach additional information if needed:
If your student has had a significant life event that continues to affect the student’s life, please provide information about the event, its impact upon
your student’s life and care tips for their time at camp. Attach additional information if needed.
Page 2 of 3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical