Please return this form to your hosting branch.

Transcription

1 CAMPER HEALTH HISTORY FORM 1 Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses Please return this form to your hosting branch. Camper Home Address: Dates will attend camp: from _to Month/Day/Year Month/Day/Year Camper Name: First Middle Last Male Female Birth Date Age on arrival at camp: Month/Day/Year To Parent(s)/Guardian(s): Please follow the instructions below. Attach additional information if needed. 1) Complete pages 1, 2, and 3 of this camper health history form (Form1) Street Address City State Zip Code Parent/guardian with legal custody to be contacted in case of illness or injury: Name: to Camper: Preferred Phones: ( ) ( )_ Home Address: (If different from above) Street Address City State Zip Code Second parent/guardian or other emergency contact: Name: to Camper: Preferred Phones: ( ) ( )_ Additional contact in event parent(s)/guardian(s) can not be reached: Name(s): to Camper: Preferred Phones: ( ) (_ ) Allergies: No known allergies. This camper is allergic to: Food Medicine The environment (insect stings, hay fever, etc.) Other (Please describe below what the camper is allergic to and the reaction seen.) Diet, Nutrition: This camper eats a regular diet. Physical Restrictions: This camper eats a regular vegetarian diet. I have reviewed the program and activities of the camp and feel the camper can participate without restrictions. I have reviewed the program and activities of the camp and feel the camper can participate with the following restrictions or adaptations. (Please describe) Medical Insurance Information: This camper is covered by family medical/hospital insurance Yes No Include a copy of your insurance and prescription cards if appropriate; copy both sides of the card so information is readable. Health Insurance Company Policy Number Subscriber Health Insurance Company Phone Number Prescription Provider Policy Number Subscriber Parent/Guardian Authorization for Health Care: Prescription Provider Phone Number This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a "need to know" basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of my child s health record from providers who treat my child and these providers may talk with the program s staff about my child s health status. Signature of Custodial Parent/Guardian Date: to Camper: If for religious or other reasons you cannot sign this, contact the camp for a legal waiver which must be signed for attendance. Page 1/3 First Middle Last Camper Name (For Camp Use) Cabin or Group

2 CAMPER HEALTH HISTORY FORM 1 Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses Camper Name: First Middle Last Birth Date: Month/Day/Year Immunization History: Provide the month and year for each immunization. Starred ( ) immunizations must be current. Copies of immunization forms from health-care providers or state or local government are acceptable; please attach to this form. Immunization Dose 1 Diptheria, tetanus, pertussis, (DTaP) or (TdaP) Tetanus booster (dt) or (TdaP) Dose 2 Dose 3 Dose 4 Dose 5 Most Recent Dose Mumps, measles, rubella (MMR) Polio (IPV) Haemophilus influenza type B (HIB) Pneumococcal (PCV) Hepatitis B Hepatitis A Varicella (chicken pox) Had chicken pox Date: Meningococcal meningitis (MCV4) Tuberculosis (TB) test Date: Negative Positive If your camper has not been fully immunized, please sign the following statement: I understand and accept the risks to my child from not being fully immunized. Signature of Custodial Parent/Guardian: Date: to Camper: Medication: This camper will not take any daily medications while attending camp. This camper will take the following daily medication(s) while at camp: "Medication" is any substance a person takes to maintain and/or improve their health. All medications must be prescribed by a licensed physician. All medications must remain in the original containers with labels showing the child s name and dosing information.. Please provide enough of each medication to last the entire time the camper will be at camp. Name of medication Date started Reason for taking it When it is given Amount or dose given How it is given Breakfast Lunch Dinner Bedtime Breakfast Lunch Dinner Bedtime Breakfast Lunch Dinner Bedtime The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness and injury. Cross out those the camper should not be given. Acetaminophen (Tylenol) Phenylephrine decongestant (Sudafed PE) Antihistamine/allergy medicine antihistamine/allergy medicine (Benadryl) Sore throat spray Lice shampoo or cream (Nix or Elimite) Calamine lotion Laxatives for constipation (Ex-Lax) Ibuprofen (Advil, Motrin) Pseudoephedrine decongestant (Sudafed) Guaifenesin cough syrup (Robitussin) Diphenhydramine Dextromethorphan cough syrup (Robitussin DM) Generic cough drops Antibiotic cream Aloe Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol) Copyright 2008 by American Camping Association, Inc. Page 2/3 Rev. 1/2007 LEE/EAW

3 CAMPER HEALTH HISTORY FORM 1 Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses Camper Name: First Middle Last Birth Date: Month/Day/Year General Health History: Check "Yes" or "No" for each statement. Explain Yes answers below. Has/does the camper: 1. Ever been hospitalized? Yes No 11. Had fainting or dizziness? Yes No 2. Ever had surgery? Yes No 12. Passed out/had chest pain during exercise? Yes No 3. Have recurrent/chronic illnesses? Yes No 13. Had mononucleosis ("mono") during the past 12 months? 4. Had a recent infectious disease? Yes No 14. If female, have problems with periods/menstruation? Yes No 5. Had a recent injury? Yes No 15. Have problems with falling asleep/sleepwalking? Yes No 6. Had asthma/wheezing/shortness of breath? Yes No 16. Ever had back/joint problems? Yes No 7. Have diabetes? Yes No 17. Have a history of bedwetting? Yes No 8. Had seizures? Yes No 18. Have problems with diarrhea/constipation Yes No 9. Had headaches? Yes No 19. Have any skin problems? Yes No 10. Wear glasses, contacts, or protective eyewear? Yes No 20. Traveled outside the country in the past 9 months? Yes No Please explain Yes answers in the space below, noting the number of the questions. For travel outside the country, please name countries visited and dates of travel. Yes No Mental, Emotional, and Social Health: Check "Yes" or "No" for each statement. Has the camper: 1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)?... Yes No 2. Ever been treated for emotional or behavioral difficulties or an eating disorder?... Yes No 3. During the past 12 months, seen a professional to address mental/emotional health concerns?... Yes No 4. Had a significant life event that continues to affect the camper s life?... Yes No (History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others) Please explain Yes answers in the space below, noting the number of the questions. The camp may contact you for additional information. Health-Care Providers: Name of camper s primary doctor(s): Phone: ( _) Name of dentist(s): Phone: ( _) _ Name of orthodontist(s): Phone: ( _) What Have We Forgotten to Ask? Please provide in the space below any additional information about the camper s health that you think important or that may affect the camper s ability to fully participate in the camp program. Attach additional information if needed. Copyright 2008 by American Camping Association, Inc. Page 3/3 Rev. 1/2007 LEE/EAW

4 FORM 2 MULTIJURISDICTIONAL AUTHORIZATION AND RELEASE FOR MEDICAL AND DENTAL IMPORTANT: This section must be completed for attendance. * The undersigned, as the parent or parents, or legal guardian or legal guardians, of the abovenamed person, a minor (the minor ), hereby authorize the YMCA of Metropolitan Los Angeles and its authorized directors and leaders (collectively the YMCA ) to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care (collectively medical care ) to be rendered to the minor under the general or special supervision and upon the advice of a physician or surgeon licensed under the laws of the state or other jurisdiction in which medical care is sought, and to consent to any x-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care (collectively dental care ) to be rendered to the minor by a dentist licensed under the laws of the state or other jurisdiction in which dental care is sought. For the purpose of medical care or dental care obtained in the State of California, this authorization is given pursuant to the provisions of Section 25.8 of the California Civil code, as amended. For the purpose of medical care or dental care obtained outside of California, this authorization is given with the intent that any consent given pursuant to this authorization shall be the consent of each of the undersigned. It is understood that if time and circumstances reasonably permit, the YMCA will endeavor, but is not required, to communicate with at least one of the undersigned prior to the rendering of medical care or dental care for which consent is given pursuant to this authorization. The undersigned understand and agree that YMCA shall not be legally or financially liable for any claim arising from any medical care or dental care provided pursuant to this authorization. The undersigned hereby agree to indemnify and to hold YMCA harmless from any claim made by or on behalf of said minor arising out of any medical care or dental care provided pursuant to this authorization. This authorization is given to the YMCA for use in conjunction with any event operated by the YMCA, and shall be valid until revoked in writing by the undersigned or any of them. SIGNED SIGNED DATE DATE MEDICAL INSURANCE COMPANY POLICY NUMBER EXPIRES NOTE: The YMCA requests that, if the minor is in the custody of both parents or more than one legal guardian, both or all sign this authorization. The YMCA understands that the minor is in the custody only of the person or persons who have signed this authorization. * If for religious reasons you cannot sign this, the branch should be contacted for a legal waiver which must be signed for attendance.

5 FORM 3 RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT IN CONSIDERATION for being permitted to utilize the facilities, services, and programs of the YMCA (or for my children to so participate) for any purpose, including, but not limited to observation or use of facilities or equipment, or participation in any off-site program affiliated with the YMCA, the undersigned, for himself or herself and such participating children and any personal representatives, heirs, and next of kin (hereinafter referred to as the undersigned ) hereby acknowledges, agrees and represents that he or she has, or immediately upon entering or participating will, inspect and carefully consider such premises and facilities and/or the affiliated program. It is further warranted that such entry into the YMCA for observation or use of any facilities or equipment or participation in such affiliated program constitutes an acknowledgement that such premises and all facilities and equipment thereon and such affiliated program have been inspected and carefully considered and that the undersigned finds and accepts same as being safe and reasonably suited for the purpose of such observation, use or participation by the undersigned and such children. IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER THE YMCA FOR ANY PURPOSE INCLUDING, BUT NOT LIMITED TO OBSERVATION OR USE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION IN ANY ON-SITE OR OFF-SITE PROGRAM AFFILIATED WITH THE YMCA, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING: 1. THE UNDERSIGNED, ON HIS OR HER BEHALF AND BEHALF OF SUCH CHILDREN, HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE the YMCA, its directors, officers, employees, volunteers and agents (hereinafter referred to as "releasees") from all liability to the undersigned or such children and all personal representatives, assigns, heirs, and next of kin of the undersigned for any loss or damage, and any claim or demands on account of injury to the person or property or resulting in death of the undersigned or such children whether caused by the negligence, active or passive, of the releasees or otherwise while the undersigned or such children is in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with the YMCA. 2. THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releasees, and each of them, from any loss, liability, damages or costs they may incur, whether caused by the negligence, active or passive, of the releasees or otherwise while the undersigned or such children is in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with the YMCA. 3. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR, AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE to the undersigned or such children due to negligence, active or passive, of releasees or otherwise while in, about or upon the premises of the YMCA and/or while using the premises or any facilities or equipment thereon or participating in any program affiliated with the YMCA. THE UNDERSIGNED further expressly agrees that the foregoing RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law of the State of California and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT, and further agrees that no oral representations, statements or inducement apart from the foregoing written agreement have been made. THIS AGREEMENT DOES NOT APPLY TO LICENSED CHILD CARE SERVICES. I HAVE READ THIS RELEASE Date Printed Name Signature of Applicant/Guardian Name(s) of Child(ren) in Program and/or YMCA Facility Revised 5/22/08

6 PHOTO & VIDEO/AUDIO RECORDING RELEASE PLEASE PRINT I am eighteen years of age or older, and if not, then my Mother/Father/Legal Guardian has also signed below under my signature. With regard to my participation in activities sponsored by or related to any activity in which I participate in any way sponsored by the National Council of Young Men s Christian Associations of the United States of America, and to any YMCA of the USA Association, including the Young Men s Christian Association of Metropolitan Los Angeles (collectively, YMCA ), I hereby give my permission and consent, now and for all time (without any further compensation, claim or demand by me) to the YMCA, and to advertising agencies, agents, entities and third parties collaborating with the YMCA and their representatives, if any, (the Organizations ) to make, reproduce, edit, broadcast or rebroadcast any video, film, or digital footage and other sound track recordings, or photo reproductions of my image or voice in any form, and my narrative account of my experience with YMCA activities ( Materials ) for publication, display, sale or exhibition thereof in promotions, advertising and legitimate business uses without any further compensation to me. I may or may not be identified by name in such reproductions. However, I shall not be stated by name to have endorsed any particular commercial products or commercial services without my express written permission. I further agree to the following: Any Materials created subject to this Release shall belong to the YMCA as its property, with full right of disposition of them without my oral or written permission. The Materials will not be subject to any obligation of confidentiality and may be shared with and used by the Organizations, as well as with any third parties as the YMCA may elect. The YMCA shall not be liable for any claim arising from the use or disclosure to a third party of any of the Materials. The YMCA shall exclusively own all known or later existing rights to the Materials worldwide and shall be entitled to the unrestricted use of the Materials for any purpose without compensation to me or the provider of the Materials. AGREEMENT AND CONSENT I have read and understood the contents of this Release. I agree that my consent to this Release is irrevocable. I hereby voluntarily release and discharge the YMCA and the Organizations and their representatives from any and all claims arising out of or relating to or in connection with the uses and reproductions of my image and voice and my narrative account as described herein. I understand that the term YMCA in this Release specifically includes the YMCA of Metropolitan Los Angeles. Signature Date / / Age Address Phone Cell Phone Address I am the Mother/Father/Legal Guardian of. I have read and understand PLEASE PRINT the contents of this Release and hereby voluntarily consent to this Release on behalf of my minor child. Signature of Mother / Father / Legal Guardian Date / / Address Phone Cell Phone Address

7 CAMPER INFORMATION SHEET FORM 5 To be completed by camper (with parent/guardian s help) Camper s Name Age Do you have a nickname? If so, what is it? Have you attended a Resident Camp before? If so, which one? What are you MOST looking forward to at Camp? Will you have any problems participating in any of the Camp activities? If so, which and why? Any special likes, dislikes, and talents we should know about? Are you allergic to any foods? Are there any foods you just WILL NOT eat? (Camper s Signature) (Parent s or Guardian s Signature)

8 CAMPER BEHAVIOR CONTRACT FORM 6 Dear Parent, It is important that you take the time to read this contract with your child so you both understand the behavior expected at the YMCA camps. We want to ensure a great experience. We ask that you read the following with great care, then sign and return it to the YMCA along with all of the other camp forms due by orientation night. I (camper s name), agree to the following terms: 1) I will assume responsibility for my actions. 2) I will participate to the best of my ability in all activities. 3) I will be respectful to all adults, campers and surroundings. 4) I will respect the rights of fellow campers and not be disruptive. 5) I will avoid conflicts with my peers, especially fighting or threats. 6) I will adhere to all rules of the YMCA and the YMCA camp that I am attending, including but not limited to the following: Refrain from any act of vandalism, destruction of property or misuse of facility. o Parents will be liable for payment to replace or repair damages. Possession and or consumption of alcoholic beverages, cigarettes, or other smoking materials are strictly prohibited. Illegal drugs and all weapons are strictly prohibited. Theft or activities that endanger the health and safety of you or others or any intimate sexual behavior is unacceptable and is not allowed. Under the terms of this agreement, offenses may be dealt with in the following manner: Camper/Counselor Conference Call home to parents Dismissal from Camp at Parents expense. o In this case no refunds will be made. If a child is sent home it is the parent s responsibility to pick up the child at camp or to pay for transportation tickets for the child and 2 counselors to accompany the child back. I have read, understand and agree to the YMCA behavior contract. Camper Signature Parent/Guardian Signature