2012 health form 12-12-201

YMCA Camper Health History Form 2012
This form MUST be BROUGHT with you to Camp. Please do not mail it.
Medical Information (please check all that apply):
For each check, please explain: _____________________________________________________________________________________
__________________________________________________________________________________________________________________
Please note: If your child has any of the following conditions they cannot attend camp until a physician has given authorization: Asth-
ma, Heart Defect/Disease, Seizures, Diabetes. In the event that your child has one of these conditions please bring a doctors note indicating
that the child may participate in all camp activities (restricted activities can be noted as well).
Has your child ever been stung by a bee before? If so, please explain how the child reacted physically.___________________________ ______________________________________________________________________________________________________________________________________________________________ Are your child’s Immunization Records up to date? _____________________________________________________________________________________________ Date of last Tetanus Shot?____________________________________________________________________________________________________________________________ Current Medications to be continued at camp (dosage & frequency): ______________________________________________________________________ (All prescription medications must be in the original container. We can not vary from instructions on container.) Any known allergies?: __________________________________________________________________________________________________________________________________ Any dietary restrictions?:_____________________________________________________________________________________________________________________________ Any reason to restrict activity?: _____________ Any current physical, mental, or psychological conditions requiring medication, treatment, or special restrictions or consid-erations while at camp?_______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________ Non-Prescription Medications: Please initial to authorize the following medications to be administered as needed Waiver of Liability– Signature required for camp attendance. I, the undersigned parent/person having legal custody/guardianship of the above said minor, give permission for the minor to participate in the program described in the YMCA Camp brochure. I authorize the YMCA to have and use photographs, slides, and/or video of my child as may be needed for it’s public relations programs. The minor is physically able, and mentally prepared to participate in all activities as described in the announcement for the program. I hereby voluntarily and knowingly assume all risks and dangers in-herent and incidental to the activities of the program. I will not hold the YMCA liable for any injuries incurred during the program whether caused by equipment or the acts of omission by others excepting the damage or injury solely caused by the willful misconduct or negligence of the YMCA or its employees or agents. I do hereby authorize the YMCA as agent for the undersigned, to consent with the respect to the minor, to any x-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is rendered under general or special supervision of, any physician and surgeon licensed under the State of Oregon, on the medical staff of any hospital, whether such diagnosis or treatment is rendered at the office of the physician or at the hospital. I understand that the YMCA is not responsible for the costs incurred for the medical care. If I participate in the program, whether as a coach, instructor, aide, spectator, or participant, I presently waive as to the YMCA and staff, officers and directors thereof, any claim presently known or unknown for damage to property or personal injury whether caused by equipment or the acts of omission of others including YMCA person-nel. Signature of Parent or Guardian: This form MUST be BROUGHT with you to Camp. Please do not mail it.

Source: http://youry.org/downloads/silverfalls/summer/2012%20Health%20Form.pdf