Ymcasv.org

YMCA Camp Campbell Outdoor Science School
CONFIDENTIAL HEALTH HISTORY AND CONSENT FORM
Child’s Name: First:
Parent/Guardian 1: Name:
Parent/Guardian 2: Name:
EMERGENCY CONTACTS WITH PERSONS AUTHORIZED TO PICK UP CHILD
In the case of an emergency, we will always contact the parent/guardian first. In the event a parent/guardian cannot be reached, we will contact other friends/
relatives. No adults other than the parent/guardian or people listed below can pick up your child from our program without a legibly written, dated and signed
note from the parent/guardian.
MEDICAL CAREGIVERS (INFORMATION REQUIRED BY STATE LAW)
Family
Immunization History and Health Examination* (include dates): Tetanus Booster: If you do not immunize your child, please sign here:
If you do not have medical insurance for your child, please sign here:
YMCA CAMP CAMPBELL PARTICIPANTS: A copy of your child’s current immunization record is recommended. A health examination is recommended
by a licensed physician within 12 months of attending the Outdoor Science School.
MEDICAL HISTORY
 ADD/ADHD
 Bleeding/Clotting Disorder  Celiac Disease List other medical history, past serious medical treatment such as operations, injuries or restrictions on physical activities here: Allergies:
 Pollen
Bee Stings:  Unknown  Yes  Bee Sting Kit List other allergies here (including insect stings, over-the-counter medications, etc.): MEDICAL HISTORY CONTINUED
Any reason to restrict strenuous activity such as swimming, long hikes or strenuous games?  YES
Is your child currently involved in therapy? Does your child require special accommodations?  YES  NO Please explain: Be sure to contact the Program Director prior to the start of the program, if your child needs special accommodations.
MEDICATION DISBURSEMENT AUTHORIZATION
If your child is currently taking prescription medications, complete this section. For your child’s protection, our staff cannot administer medication without this form.
Any medicines that you give us for your child must be in the original container with dosage directions and/or doctor’s instructions clearly labeled. Medication will be
administered and documented according to directions on the bottle or by a doctor’s instructions.
YMCA Camp Campbell Participants and Family Campers:
I authorize the following over-the-counter medications to be administered as needed:
SWIMMING/SUNSCREEN INFORMATION
Some YMCA programs may include swimming activities with certified lifeguards on duty. For your child’s safety, every child with permission to swim, regardless of
swimming ability, will have to take a YMCA swimming test prior to swimming.
My child has permission to participate in YMCA swimming activities. The YMCA staff may apply sunscreen to my child’s exposed skin (not covered by clothing/swimsuit), as needed.
PHOTO RELEASE
I hereby irrevocably consent to and authorize the use and reproduction by the YMCA, or anyone authorized by the YMCA, or any and all photographs which you
have this day taken of my child, negative or positive, for any purpose whatsoever without compensation to me. All negatives and positives, together with the print,
shall constitute the YMCA’s property, solely, and completely.
MEDICAL RELEASE
This health history is correct, so far as I know, and the person herein has permission to engage in all prescribed program activities. I assume that the YMCA of
Silicon Valley assumes no financial obligation for such treatment but, in the event that I cannot be reached for an emergency, I hereby give permission to the
physician selected by the YMCA to order X-rays, routine tests, and secure proper treatment, hospitalize, and to order injections/and/or anesthesia and/or surgery
and emergency treatment for my child as named on this form.
I agree to and understand the following guidelines: Participants agree to abide by the rules and regulations set by the YMCA for the health, safety, and
welfare of all children. Children are not allowed to smoke, chew tobacco, possess any smoking materials, alcohol, illegal drugs, firecrackers or explosives, weapons,
use lewd conduct, and inappropriate touching of any kind. Willful destruction of property will be the financial responsibility of the child’s parent. Children may not
leave the property or established boundaries without YMCA staff permission.
YMCA of Silicon Valley reserves the right and will send anyone home (at parents’/guardians’ expense and liability) who violates these rules. It is the responsibility of the parent/guardian to pick up or arrange transportation home for the child. The Program Director reserves the right to determine what constitutes a violation of these rules and will enforce them as necessary.
Parent’s/guardian’s signature is required on the Photo Release, Medical Release and agreement to follow YMCA policies and guidelines in order for your child to participate in the YMCA program.

Source: http://www.ymcasv.org/ymcacampcampbell/pdfs/ccoss_healthform_english.pdf