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“ ' Dates will attend camp from to

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									                                      YMCA CAMP MOHAWK HEALTH FORM
                       (Parents must complete this form and return to camp by June 1st.)
                        This information is confidential to Camp Directors, Nurses, and First Aiders.
         It will be shared with appropriate staff if deemed to be in the camper’s best interest by the Camp Nurse.

Camper: __________________________________________ Birth Date: _________ Age at camp: ____
          Last                             First                          Middle

Home Address: ________________________________________________________________________
                   Street                                          City                      State             Zip

Home Phone: ______-_________-________

Custodial Parent(s) or Guardian(s):______________________________________________________

Address (If different from above):_______________________________________________________________
                                 Street                            City                              State      Zip

Phone: ______-_________-________

If not available in an emergency, notify:

Name: ______________________________________________________________________________

Relationship: ____________________________________________ Phone:______-_________-________

Address: ____________________________________________________________________________
          Street                                          City                      State            Zip

Insurance Information

Is child covered by medical/hospital insurance?            Yes               No

If so indicate carrier Plan Name: __________________________________________________________

Identification#_______________________________                    Group#____________________________

Name of Card Holder: ____________________________ Insurance Co. Phone#____________________

         Please send copies of both sides of medical insurance card.


                         Important – This must be completed for attendance*
Parent Guardian Authorizations: This health history is correct and complete as far as I know. The person herein
described has permission to engage in all camp activities except as noted. I hereby give permission to the camp to provide
routine health care, administer prescribed 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
give permission to the camp to arrange any necessary related transportation for me/my child. In the event I cannot be
reached in an emergency, I hereby give permission to the physician selected by the camp to secure and administer
treatment, including hospitalization, for the person named above. This completed form may be photocopied for trips out
of camp.

Signature of parent/guardian or adult camper/staff______________________________________________

Printed Name___________________________________________________Date_________________


*If for religious reasons you cannot sign this, contact the camp for a legal wavier which must be signed for attendance.
Is the Camper allergic to:
Yes                                                 Is the camper taking any medications?*
       Bee Stings                                  __________________________________________
       Insect Bites                                __________________________________________
       Poison Ivy                                  __________________________________________
       Particular Foods:                           __________________________________________
_________________________________                   __________________________________________
_________________________________                   __________________________________________
                                                    If so, please have your physician fill out an Authorization for the
                                                    Administration of Medication for each medication prescribed.
     Medications:
_________________________________
                                                    Does the camper have any type of restrictions?
_________________________________
                                                    If so, please provide details:
                                                    __________________________________________
     Other:
                                                    __________________________________________
_________________________________
                                                    __________________________________________
_________________________________
                                                    Does the camper have a retainer?                        Yes
     Dietary Restrictions:
_________________________________
                                                    Date of last Tetanus Booster: ________________
_________________________________

Has the camper had or is subject to:
                                                    Name of child’s MD:________________________
Yes
     Epilepsy
                                                    Address:__________________________________
     Heart Trouble
                                                    __________________________________________
     Convulsions
                                                    __________________________________________
     Fainting
     Headaches
     Asthma/Wheezing                               Phone:____________________________________
     Homesickness
     Stomach Aches
     Other (please explain) :                      Is there any information that you would like to
_________________________________                   share that would enable us to serve your child
_________________________________                   better?
                                                    __________________________________________
Is the camper under medical care for any illness?   __________________________________________
If so, please provide details:                      __________________________________________
__________________________________________          __________________________________________
__________________________________________          __________________________________________
__________________________________________          __________________________________________
__________________________________________          __________________________________________
                                                    __________________________________________
                                                    (You may attach a note to this form)
Does the camper have any emotional difficulties
that we should be aware of?
If so, please provide details:
__________________________________________          *Any child who is to receive medication
__________________________________________          that is either prescription or over the counter that is
__________________________________________          not on our As Needed Medication Form is required
__________________________________________          by state law to have the Authorization for the
                                                    Administration of Medication form completed and
                                                    signed by the authorized prescriber and parent.

								
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