Fillable Ymca Camp Piomingo Health Examination Form (Page 2 of 3) in pdf

Restrictions:

Restrictions

Nuts

The following dietary restrictions apply to this individual:

❑ Does not eat eggs

❑ Does not eat poultry

❑ Does not eat seafood

❑ Does not eat red meat

❑ Does not eat pork

❑ Does not eat dairy products

❑ Other (describe) __________________________________________________________

NOTE:

• Please write or call the camp if your child is exposed to or has contracted any potentially serious communicable disease

(such as chicken pox, hepatitis, meningitis, etc.) during the three weeks prior to camp attendance.

• In order to complete the registration process, this form (no substitutions) must be received by June 1

for medical staff

review. Without this completed form in our records prior to camp your child will be unable to attend.

We are proud of our health center, which is staffed by experienced registered nurses and LPN's, nurse practitioners, or E.M.T.'s.

We are proud of our health center, which may be staffed by experienced registered nurses and LPNs, nurse practitioners, or E.M.T.’s.

YMCA Camp Piomingo has a physician on call who is available for medical situations which require such attention or services. In the

YMCA Camp Piomingo has physician on call 24 hours who is available for medical situations which require such attention or services.

event of unforeseen circumstances, it is essential that the parent or guardian sign the following statement below:

In the event of unforeseen circumstances, it is essential that the parent or guardian sign the following statement.

Parent/Guardian Authorizations: This health history is correct and complete as far as I know. The person herein

Parent/Guardian Authorizations: This health history is correct and complete as far as I know. The person herein described has permission

described has permission to engage in all camp activities except as noted. I hereby give permission to the camp

Important – This box must be complete for attendance*

to engage in all camp activities except as noted. I hereby give permission to the camp to provide routine health care, administer prescribed

to provide routine health care, administer prescribed medications, and seek emergency medical treatment including

Parent/Guardian Authorizations: This health history is correct and complete as far as I know. The person herein described has

medications, and seek emergency

permission to engage in all camp activities except as noted. I hereby give permission to the camp to provide routine health care,

ordering x-rays or routine tests. I agree to the release of any records necessary for insurance purposes. I give

administer prescribed medications, and seek emergency medical treatment including ordering x-rays or routine tests. I agree to the

permission to the camp to arrange necessary related transportation for myself/my child. In the event I cannot

release of any records necessary for insurance purposes. I give permission to the camp to arrange necessary related transportation for

be reached in an emergency, I hereby give permission to the physician selected by the camp to secure and

me/my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to

administer treatment, including hospitalization, for the person named above. This completed form may be

secure and administer treatment, including hospitalization, for the person names above. This completed form may be photocopied for

trips out of camp.

photocopied for trips out of camp.

Signature of parent/guardian or adult camper/staffer ______________________________________________________________

SIGNATURE OF PARENT/GUARDIAN _______________________________________________________

Printed name __________________________________________________________________ Date ______________________

PRINTED NAME: ___________________________________________

DATE: ______________________

Please attach a copy of your insurance card.

IMPORT

Attach Insurance Card

ANT:

Front Here

Back Here

THS FORM

(NO

SUBSTITUT

IONS)

Participation Agreement

By signing this form, I understand that I am giving permission for my child to participate in YMCA Camp Piomingo summer camp

programs. Furthermore, I understand that certain risks may be involved with participation in Camp Piomingo programs, activities and

clinics that may be considered “High Risk” (i.e Equestrian, Challenge Ropes Course, Climbing, Whitewater Rafting, Kayaking, Mountain

Boarding, Canoeing etc). I also understand by signing this form, I acknowledge that during Camp Piomingo programs, activities, and

clinics that my child may or may not participate in, that certain risks and dangers may occur. These include but are not limited to, being

at various heights (ground to 50’), accident or illness in remote places, forces of nature, travel by air, train, boat, automobile, or other

conveyance, loss or damage to personal property, physical or psychological damage and/or injury not excluding fatality due to

accidents which may occur. I further understand that medical treatment may be several minutes to hours away in the event of a medical

emergency. I further state that by signing this form, I agree to assume for my child, myself, my heirs, and executors all risks of physical

injury or emotional upset which may be a result of my child’s participation in a Camp Piomingo summer camp program. In addition, I

agree to release from liability YMCA Camp Piomingo, its board of management, officers, employees, agents, and/or associates in the

event of such result. The terms hereof and my signature on this document shall bind my heirs, representatives, executors, and

administrators, successors, and assigns and for all members of my family, including any minors accompanying me.

Name of Participant ________

_______________________________ (Please print)

Signature of Parent of Guardian ______________________________

_____Date___________________

Signature of Witness____________

________________________________Date_____________________

Scan and email to

OR mail copies of all forms to

YMCA Camp Piomingo, 1950 Otter Creek Park Road, Brandenburg, KY 40108

Health Examination Form Page 2 of 3

Ymca Camp Piomingo Health Examination Form Page 2

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