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Camper's Name:
YMCA OF SILICON VALLEY | Resident/Travel Camp Health History Form
(Complete one form per child - ALL pages - Must be submitted 3 weeks before camper's arrival)
Mail to: YMCA Camp Campbell, 16275 Highway 9, Boulder Creek, CA 95006, or fax to 831-338-9486
Child’s Name: ______________________________________________________________ o M o F Age (during camp)_______ Birth Date _____ /_____ /_____Address: ____________________________________________________________ Apt.#________ City___________________________ Zip___________________ Grade _________ Parent/Guardian 1: ______________________________________________________ Parent/Guardian 2: _______________________________________________________ Last_____________________________________________________ FirstHome Phone #: ____________________________________________________________ Home Phone #: ____________________________________________________________ Employed by: ______________________________________________________________ Employed by: ______________________________________________________________ Occupation: _______________________________________________________________ Occupation: ________________________________________________________________ Business Phone: _________________________________________________________ Business Phone: __________________________________________________________ EMERGENCY INFORMATION
Name: _____________________________________________________________________________________ Phone: _____________________________________ Relationship: _________________________________ Name: _____________________________________________________________________________________ Phone: _____________________________________ Relationship: _________________________________ Name: _____________________________________________________________________________________ Phone: _____________________________________ Relationship: _________________________________ INFO REQUIRED BY STATE LAW
VACCINES (APPROX DATE IMMUNIZED)
Health Insurance Co.: __________________________________________________________________ DPT: _____________________________________ Policy Number: __________________________________________________________________________ Tetanus: ________________________________ Family Physician: ________________________________________________________________________ Oral Polio: _______________________________ Phone: _____________________________________________________________________________________ Family Dentist: __________________________________________________________________________ Phone: _____________________________________________________________________________________ MEDICAL INFORMATION PAST OR PRESENT (PLEASE CHECk)
______________________________ Session: ______________________ ____________________________________________________ ____________________________________________________ For each Yes, please explain: __________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________ ALLERGIES & SPECIAL NEEDS (PLEASE CHECk)
Current Medications to be continued at camp (dosage/frequency): _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Dietary Restrictions? : o Yes o No ____________________________________________________________________________________________________________________________Any reason to restrict ful activity including swimming, long hikes, strenuous physical games?: o Yes o NoIf Yes, please explain: ___________________________________________________________________________________________________________________________________________________ NON-PRESCRIPTION MEDICATIONS I authorize the fol owing medications to be administered as needed:
Camper's Name:
PARENT'S AUTHORIZATION
This health history is correct, so far as I know, and the person herein has permission to engage in all prescribed program activities. I give permission to the physician selected by the YMCA to order X-Rays, routine tests, and treatment for the health of my child, and in the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the YMCA to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for my child named above. We recognize that the participant must follow safety instructions, remain in areas designated by staff and refrain from behavior that is harmful to oneself or others. Failure to adhere to program policies will be cause Last_____________________________________________________ First for participant's dismissal without refund of fees. Images of my child may be used for promotional purposes. Parent/Guardian Signature ___________________________________________________________________________________ Date ______________________________ CONSENT TO SEARCH CAMPER’S BELONGINGS
In order to prevent harm, maintain order and safety to all campers and staff who are participating in the YMCA of the Silicon Valley camping activities, I (parent) hereby give permission to YMCA staff to search my camper’s belongings when there is reasonable suspicion that the camper has possession of illegal or dangerous items (i.e./ weapons, knives, alcohol, illegal drugs, fireworks or explosives) or the camper seriously violates camp rules and evidence of the infraction can be found through a search of the camper’s personal belongings. To the extent possible, the camper will be present during such a search and the scope of the search will be limited to their personal belongings. Parent/Guardian Signature ___________________________________________________________________________________ Date ______________________________ MEMO OF UNDERSTANDING (To be read, understood and signed by Camper and Parent)
We welcome you to our YMCA of Silicon Valley camping programs. In order to provide the best possible experience for everyone, there are certain rules and policies that have been established for the health and safety of all involved. 1. The camper agrees to abide by the rules and regulations set by the camp for the health, safety and welfare ______________________________ Session: ______________________ 2. Campers are not allowed to smoke, chew tobacco, possess any smoking materials, alcohol or illegal drugs.
3. All medications/prescribed drugs must be kept in a secure location under the control of the Health Supervisor.
4. Campers are not to possess or use firecrackers or explosives. Campers may not possess weapons of any kind.
5. Willful destruction of property will be the financial responsibility of the camper's parent.
6. Campers may not leave camp property or established boundaries without YMCA staff permission.
7. Continued inappropriate behavior, including threatening, swearing, not following directions, teasing, sexual harassment/intimidation and improper behavior in transportation vehicles, may result in IMMEDIATE DISMISSAL FROM CAMP WITH NO REFUND.
8. The YMCA is not responsible for articles of clothing or personal belongings lost or damaged.
We reserve the right and WILL send ANYONE home (at parents' expense and liability) who violates these rules. It is the responsibility of the parent/guardian to pick up or arrange transportation home for the camper. The camp administrator reserves the right to determine what constitutes a violation of these rules and will enforce them as necessary. I have read, and understood and will abide by the rules as stated above throughout my stay at camp.
Camper's Signature ____________________________________________________________________________________________ Date ______________________________ Parent/Guardian Signature ___________________________________________________________________________________ Date ______________________________ Camper's Name:
FOR RESIDENT CAMP AND TRAVEL CAMP ATTENDEES ONLY
Al campers are required to have written confirmation of a health examination within 24
months of attending Resident camp or travel camps.
REQUIRED: HEALTH ExAMINATION BY LICENSED PHYSICIAN
Camp is held at an outdoor setting, with programs that are very active, including hiking, games, swimming Last_____________________________________________________ First and traditional camp activities. Your careful consideration is appreciated.
I have examined the child named on this form within the past two years. The examination date was _______/_______/_______. After examination and my review of his/her health history, it is my opinion that this person is physical y able to engage in camp activities, except as noted below.
Is the applicant under the care of a physician for any conditions? o Yes o No If yes, please explain:_________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Any specific activities to be encouraged or limited by physician's advice?:_________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Any treatment or medications to be continues at camp (please give specific dosages): ______________________________ Session: ______________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Additional health information: _________________________________________________________________________________ _________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Licensed Physician Signature: _____________________________________________________ Date: ___________________Address: _______________________________________________________________________________ Phone: __________________Date of Form Completion: ___________________________________________________________ By: _____________________

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