Ymca Summer Day Camp Form - 2016 (Page 7 of 9) in pdf

In case of EMERGENCY, we should contact the following person(s) if parents cannot be reached:

(Please list names in order you would like them to be called)

A._______________________________________________________________________ Phone ___________________________________ Relation ________________________________

B._______________________________________________________________________ Phone ___________________________________ Relation ________________________________

C._______________________________________________________________________ Phone ___________________________________ Relation ________________________________

D._______________________________________________________________________ Phone ___________________________________ Relation ________________________________

Authorized person(s) to take child from site:

(You MUST list anyone who may pick up your child, including parents or guardians and emergency contacts)

A._______________________________________________________________________ Relation to child __________________________________________________________________

B._______________________________________________________________________ Relation to child __________________________________________________________________

C._______________________________________________________________________ Relation to child __________________________________________________________________

D._______________________________________________________________________ Relation to child __________________________________________________________________

Please list any additional names on an additional sheet of paper.

Please speak with the Director if there is a person that is NOT authorized to pick-up or see child.

GENERAL HEALTH QUESTIONS

Medication, if any:________________________________________________________________ Possible side effects: ______________________________________________

□ Yes

□ No

Will this medication be taken while he/she is at Summer Day Camp?

Please note, it is the parent’s responsibility to supply the staff with the medication paperwork and directions.

Any recent operations, accidents, broken bones, vision or hearing conditions, or illnesses we should be aware of? ________________

__________________________________________________________________________________________________________________________________________________________________

Any special devices used (glasses, hearing aids, crutches, etc.)? ________________________________________________________________________________

Date of last tetanus shot _________________________________________________________________________________________________________________________________

Names and ages of child’s brothers and sisters: _____________________________________________________________________________________________________

Does your child have any fears we should be aware of? (insects, water, heights, animals, etc.) __________________________________________

__________________________________________________________________________________________________________________________________________________________________

Has any event occurred that could cause an emotional concern that we should be aware of? (Death in the family, divorce, etc.?)

__________________________________________________________________________________________________________________________________________________________________

Any known intolerance to food, insect bites/stings, or other factors that result in medical reaction? Please provide us with

clear instructions in the event of an exposure to the factor.

AUTHORIZATION FOR EMERGENCY MEDICAL CARE

I (we) expect to be notified at once in case of accident or illness to my/our child; I/we will make arrangements for medi-

cal care of my/our child with the physician or hospital of my/our choice; If I/we cannot be reached to make the

necessary arrangements, I/we hereby authorize the YMCA to contact:

Dr._________________________________ at_______________________________________________________________________________________________________

ADDRESS

PHONE

or the nearest hospital for emergency medical treatment of _______________________________________________________________________

CHILD’S NAME

Furthermore, I/we certify that my child is, to my/our knowledge, in good health and free of disabilities that would

endanger him/her or other children in the YMCA programs.

Parent’s signature_____________________________________________________________________________________ Date_____________________________

YMCA OF GREATER OMAHA . . Page 7

Ymca Summer Day Camp Form - 2016 Page 7

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