Westsuburbanymca.org

HealtH History Form
West sUBUrBaN ymCa
Health History Forms must be filled out by a parent/guardian. Please complete all pages. Incomplete or unsigned forms will be returned to you. Please return the completed forms and other documentation via email: campingservices@westsuburbanymca.org, Fax 617-321-2267 or mail to West Suburban YMCA, Attn: Camping Services Branch 276 Church Street, Newton, MA 02458 In addition to this completed form, the following must be submitted in order to complete your
camper’s health record: Any missing pieces will delay processing.
☐ This health history form (including required signature on page 3)☐ Copy of child’s most recent physical exam within the past 12 months OR page 4 of this form filled out by a licensed health care provider☐ Certificate of immunizations signed by a licensed health care provider☐ Photocopy of front and back of insurance card☐ Please keep a copy of the completed form for your records camper's name:____________________________________________________________________ camper home address: ______________________________________________________________BIrTh daTe: ______/______/______ parenT / guardIan #1 InformaTIon parenT / guardIan #2 InformaTIon Street Address (if different from Parent / Guardian #1) famIly emaIl address: (used for confirmations & important updates) emergency phone numBer: (one number where you can be contaced in the event of an emergency)who has legal cusTody of The camper? Both Parents Parent/Guardian 1 Parent/Guardian 2 OthercommunIcaTIon: We will be sending confirmations and additional paperwork to the family email adress listed. If you prefer to receive these in the mail, please contact us directly. please lIsT addITIonal conTacTs, otHer tHaN pareNts, ThaT we may conTacT In The evenT of an emergency
and ThaT are auThorIzed To pIck up The camper. a phoTo Id Is requIred aT pIck up.
unauThorIzed pIck ups requIre documenTaTIon. please ask us for more InformaTIon.
Camper's pHysiCiaN iNFormatioN:
Name:
Camper's DeNtist/ortHoDoNtist iNFormatioN:
Name:
iNsUraNCe iNFormatioN:
Is the camper covered by family medical/hospital insurance?
Camper's meDiCal History:
The following information must be filled in by the parent/guardian. This information is intended to provide camp health care
personnel with the background to provide appropriate care. Please keep a copy of the completed form for your records. Any changes to this form should be provided to the camp health personnel upon arrival. Complete information must be provided to ensure camp is aware of your camper's needs. If "NONE" please indicate that clearly below - do not leave blank.
allergies: list all kNoWN.
Medication Allergies:
Describe reaction and management of the reaction Describe reaction and management of the reaction Describe reaction and management of the reaction restriCtioNs:
Explain any limitations to activity (i.e. what can not be done at all or what adaptations are necessary for participation) ☐ None
Camper does not eat: ☐ red meat ☐ pork ☐ poultry ☐ seafood ☐ eggs ☐ dairy products ☐ nuts & nut products ☐ other: meNtal, emotioNal aND soCial HealtH
Has the camper:
Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (ADHD)? ☐ Yes Ever been treated for emotional or behavioral difficulties or an eating disorder? During the past 12 months, seen a professional to address mental/emotional health concerns? Had a significant life event that continues to affect the camper's life?(history of abuse, family change, etc.) ☐ Yes Please explain any YES answers and describe any current physical, mental or psychological conditions requiring medication, treatment or special considerations at camp. Please specify circumstances that you would like to be contacted (i.e. a diabetic who has blood sugar less than 70 or greater than 250) and briefly describe anything we should know about your child such as disabilities, IEP, etc. Feel free to attach an- other sheet of paper if more room is needed. meDiCatioNs:
Please list ALL medications, including over-the-counter or nonprescription drugs taken routinely. Bring enough medication to
last the entire time at camp. Medication must be in the original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage and the frequency of administration. All medications must be given to the camp nurse or health care supervisor on the first day at check-in.
☐ None☐ As of _____/_____/2014, this person takes the following medications: Identify any medication taken during the school year that the participant does/may not take during the summer: appliCaBle to Camp FraNk a. Day aND Camp CHiCkami Campers oNly: The following non-prescription medications
are commonly stocked in the nurse's office and used on an as needed basis to manage illness and injury. These medica-
tions will be given only by the registered nurse present at camp. Cross out items that should not be given to the
camper.
Acetaminophen (Tylenol)
Laxatives for constipation (Ex-Lax) Dextrometh/Guaifenesin (Tussin) Lice shampoo/Scabies Cream (Nix or Elimite) QUestioNNaire:
Has/does the camper:
12. Passed out/chest pain during exercise? 13. Had mononucleosis during the past year? ☐ Yes ☐ No 14. Have problems with menstruation/periods? ☐ Yes ☐ No 6. Had asthma/wheezing/short breath ☐ Yes ☐ No 18. Have problems with diarrhea/constipation? ☐ Yes ☐ No 20. Traveled outside USA the past 9 mos.? Please explain any YES answers in the following space, noting the number of the question: pareNt/gUarDiaN aUtHoriZatioN
This health history is correct and complete to the best of my knowledge. The person herein described has permission to
engage in all camp activities, except noted. I hereby give permission to the camp to provide routine health care, administer prescribed and over-the-counter medications and seek emergency medical treatment, including ordering x-rays or routine tests. I agree to the release of any records necessary for treatment, referral, billing or insurance purposes. I understand that I and/or my insurance company are responsible for the expenses incurred. I give permission to the camp to arrange neces- sary related transportation for my child. In the event I can not be reached in an emergency, I hereby give permission to the physician selected by the camp to secure and administer treatment, including hospitalization, for my child. This completed A non-refundable, non-transferable $100 deposit per camper PER SESSION is required to hold a spot at camp. The balance of the tuition is due April 15, 2014. If you wish to set up a payment plan, please be sure to download the form from www.westsuburbanymca.org, or contact Camping Services at 617-244-6050, x3008 to request one. Full payment must be reFUND poliCy
There are no refunds of the deposit. Refunds of tuition paid minus deposit will only be granted prior to March 1, 2014 with a written request for a refund. Refunds of tuition on or after March 1, 2014 may only be considered for serious medical reasons causing camper withdrawal upon written advice from a physician. Campers who arrive late, depart early or miss days are not granted pro-rated fees of refunds even if requested before March 1, 2014. No refunds are given for campers who decide they do not like camp, have minor illness, are homesick, are removed from camp for disciplinary reasons, and/or changes of pHotograpHy/ViDeo
I hereby authorize the YMCA to take, have and use photographs, slides or videos as may be needed for its records for public relations purposes. Please initial your choice - if denied, please attach a photograph of your child to this application to ensure we do not While it is the aim and the responsibility of the West Suburban YMCA to provide your child with a safe and enjoyable experi- ence, please realize that participation in YMCA programs has some inherent risks. I hereby authorize that my child is ready to experience an active camp setting. I give permission for him/her to participate in all planned camp activities and programs, including field trips, the climbing wall, and the skate park. I hereby release for myself and my child, our heirs, executors and administrators, and forever discharge the West Suburban YMCA its agents, servants, representatives and employees for any injuries, loss, liability, damage or costs which my child may receive / incur as a result of participation in any program/activity/ service conducted and/or provided by the West Suburban YMCA. I understand that there will be other forms as listed in the family handbook that must be submitted before the camper can participate in camp. The camper may not participate in camp until all paperwork is received. I will keep a copy of all paper- work for my records and will provide upon request. please Note: All campers must submit this page fil ed out by a licensed physician. It is acceptable to attach a doctor's form
here and write "see attached" for this page if you do not have this form with you at the time of your doctor's appointment.
Remember to attach a copy of your child's immunization record and the front and back of your health insurance card.
pHysiCal examiNatioN By a liCeNseD HealtH Care proViDer
I examined this individual on_____/_____/20___. (Must be dated after 8/31/2013) BP__________ Weight __________ Height__________ Temperature __________ In my opinion, this applicant ☐ is ☐ is not able to participate in an active camp program.
The applicant is under the care of a physician for the following condition(s): Recommendations and Restrictions at Camp:
Medications to be administered at camp (name, dosage, frequency): Any medically-prescribed meal plan or dietary restrictions: Description of any limitations or restrictions on camp activities: Additional information for health care staff at camp: Signature of Licensed Health Care Provider:
For Camp Use oNly:
Session
Medication receivedUpdates/additions to health history notedCurrent health needs identifiedObservational notesScreened by

Source: http://www.westsuburbanymca.org/sites/default/files/uploads/Health%20History%20Form%20Web.pdf