Ymca Camp Piomingo Health Examination Form
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YMCA CAMP PIOMINGO HEALTH EXAMINATION FORM
Health Examination Form
THIS SIDE TO BE COMPLETED BY PARENT OR GUARDIAN AND SIGNED PRIOR TO REVIEW BY A PHYSICIAN.
ALL FORMS DUE PRIOR TO YOUR CAMPER’S ARRIVAL TO CAMP:
Scan and email to
OR mail copies of all forms to
YMCA Camp Piomingo, 1950 Otter Creek Park Road, Brandenburg, KY 40108
Camper Last Name
First Name
MI
/
/
❑ Male ❑ Female
Birth date
Age at camp
Gender:
Home address
City
State
Zip
Custodial Parent/Guardian
Home phone
Cell phone
Email
Business name
Business address
City
State
Zip
Work phone
Cell phone
Second Parent or Guardian or Emergency Contact
Address
City
State
Zip
Business address
City
State
Zip
Home Phone
Cell phone
Work Phone
If not available in an emergency, notify
Name
Relationship
Address
City
State
Zip
Home Phone
Cell phone
Work Phone
HEALTH HISTORY: Please check and attach a separate statement regarding potential problem areas:
❑ Recurring Strep Throat
❑ Bed Wetting
❑ Tuberculosis
❑ Asthma
❑ Heart Disorder
❑ Hepatitis
❑ Chronic Constipation
❑ Sleep Walking
❑ Serious Injuries
❑ Chronic Cough
❑ Fainting
❑ Chicken Pox
❑ Frequent Ear Infections
❑ Seizures
❑ Infectious Mononucleosis
❑ Other
❑ Severe Headaches/Migraines
❑ ADD/ADHD Learning Disabilities ❑ Kidney Problem/Urinary Tract Infection
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For female campers – Has your daughter menstruated? ❑ Yes ❑ No Has she been told about menstruation? ❑ Yes ❑ No
Allergic Reactions: (Please give details)
Insect stings
Poison ivy/oak
Medications
Other
Has your child been evaluated or received treatment or counseling by a psychologist or physician for an emotional or behavioral
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problem, including hyperactivity? ❑ Yes ❑ No If so, on a separate statement, please help us understand how to effectively address
these concerns.
Are there other special concerns regarding your child’s health or medical history? (attach separate statement, if necessary)
Scan and email to
OR mail copies of all forms to
Health Examination Form Page 1 of 3
YMCA Camp Piomingo, 1950 Otter Creek Park Road, Brandenburg, KY 40108
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