YMCA Camp Copneconic Health History & Release Form

* Please be sure to fill out the form entirely as it is not possible to save and finish it later. Thank you.

Your camper will attend camp from: on

Camper Information:

 
First Name: Middle Name:
Last Name:
Male Female Birth Date:

Month/Day/Year 		Age at Camp:
    

Camper Home Address:

     
Street Address:
City:

State:
 Zip Code:
   

Parent/Guardian with legal custody to be contacted in case of illness or injury:

Name:
 Relationship to Camper:
Preferred Phone:
Home Address (if different than above):  
Second parent/guardian or other emergency contact:  
Name:
Relationship to Camper:
Preferred Phone:
Additional contact in event parent(s)/guardian(s) cannot be reached:  
Name(s):
 Relationship to Camper:
Preferred Phone:

Allergies:
No Known Allergies  
This camper is allergic to: Food Medicine The environment (insect stings, hay fever, etc.) Other
(Please describe below what the camper is allergic to and the reaction seen.)

Diet, Nutrition:

    
This camper eats a regular diet.
This camper eats a vegetarian diet.
This camper has special food needs.		    
(Please describe any special food needs.)    
   
(The following restrictions apply to this individual.)    
Red Meat 
Pork 
Dairy Products  		Poultry 
Seafood 
Eggs 		 Other 
Restrictions: I have reviewed the program and activities of the camp and feel the camper can participate without restrictions.
  I have reviewed the program and activities of the camp and feel the camper can participate with restrictions.
  (Please describe below.)
 

Medical Insurance Information:
This camper is covered by family medical/hospital insurance Yes  No
Insurance Company:
 		 Policy Number:
Subscriber:
 		 Insurance Company Phone Number:
Please fax, mail, or bring in a copy of your campers’ insurance information.

Parent/Guardian Authorization for Health Care:
This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine test, and treatment related to the health of my child for both routine health care and in emergency situation. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for and order injection, anesthesia or surgery for this child. I understand the information on this form will be shared on a "need to know" basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of my child's health record from providers who treat my child and these providers may talk with the program's staff about my child's health status.

Electronic Signature of Custodial Parent/Guardian: Date:
Relationship to Camper:
If for religious reasons you cannot sign this, contact the camp for a legal waiver which must be signed for attendance.  
General Health History: Check "Yes" or "No" for each statement. Explain "Yes" answers below.  
Has/does the camper:      
1. Ever been hospitalized? Yes   No 11. Had fainting or dizziness? Yes   No
2. Ever had surgery? Yes   No 12. Passed out/had chest pain during exercise? Yes   No
3. Have recurrent/chronic illnesses? Yes   No 13. Had mononucleosis (“mono”) during the past 12 months? Yes   No
4. Had a recent infectious disease? Yes   No 14. If female, have problems with periods/menstruation? Yes   No
5. Had a recent injury? Yes   No 15. Have problems with falling asleep/sleepwalking? Yes   No
6. Had asthma/wheezing/shortness of breath? Yes   No 16. Ever had back/joint problems? Yes   No
7. Have diabetes? Yes   No 17. Have a history of bedwetting? Yes   No
8. Had seizures? Yes   No 18. Have problems with diarrhea/constipation? Yes   No
9. Had headaches? Yes   No 19. Have any skin problems? Yes   No
10. Wear glasses, contacts or protective eyewear? Yes   No 20. Traveled outside the country in the past 9 months? Yes   No

Please explain "Yes" answers in the space below, noting the number of the question. For travel outside the country, please name countries visited and dates of travel.

 
Mental, Emotional, and Social Health: Check "Yes" or "No" for each statement.  
Has the camper:  
1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)? Yes   No
2. Ever been treated for emotional or behavioral difficulties or an eating disorder? Yes   No
3. During the past 12 months, seen a professional to address mental/emotional health concerns? Yes   No
4. Had a significant life event that continues to affect the camper’s life? Yes   No
(History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others.)  

Please explain "Yes" answers in the space below, noting the number of the question. The camp may contact you for additional information.

Health Care Providers:  
Name of camper's primary doctor:
 Phone:
Name of dentist:
 Phone:
Name of orthodontist:
Phone:

The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness and injury.

Please check those the camper should NOT be given.  
Acetaminophen (Tylenol) Ibuprofen (Advil, Motrin) Ibuprofen (Advil, Motrin)
Phenylephrine decongestant (Sudafed PE) Pseudoephedrine decongestant (Sudafed)
Antihistamine/allergy medicine Guaifenesin cough syrup (Robitussin)
Diphenhydramine antihistamine/allergy medicine (Benadryl) Dextromethorphan cough syrup (Robitussin DM)
Sore throat spray Generic cough drops
Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol) Aloe
Laxatives for constipation (Ex-Lax) Calamine lotion
Antibiotic cream  

Medications Being Taken:
Please list ALL medications (including over-the-counter or non-prescription drugs) taken routinely. Bring enough medication to last the entire time at camp. Keep it 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.

This person takes No medications on a routine basis. 
This person takes medications as follows:

Med #1
 Dosage:
 
Specific times taken each day:
 Reason for taking:
Med #2
 Dosage:
 
Specific times taken each day:
 Reason for taking:
Med #3
 Dosage:
 
Specific times taken each day:
 Reason for taking:
Med #4
 Dosage:
 
Specific times taken each day:
 Reason for taking:

Identify any medications taken during the school year that participant does/may not take during the summer:

Immunization History:Provide the month and year for each immunization. Starred (*) immunizations must be current. Copies
of immunization forms from health care providers or state or local government are acceptable; if included, either fax to 810 629 2128 or mail to YMCA Camp Copneconic, 10407 N. Fenton Rd Fenton, MI 48430.

NOTE: Writing “Up To Date” is not acceptable.

Immunization Month/Year Month/Year Month/Year Month/Year Month/Year Month/Year
Diptheria, Tetanus, Pertussis*
(DTap) or TdaP)
Tetanus booster *
(dT) or TdaP)
Mumps, Measles, Rubella*
(MMR)
Polio*
(IPV)
Haemophilus Influenzae Type
B (HIB)
Pneumococcal
(PCV)
Hepatitis B
Hepatitis A
Varicella
(Chicken Pox)
Meningococcal meningitis
(MCV4)
Tuberculosis (TB) Test Date:
  Positive  Negative

 

Which of the following has the participant had?    
Measles Mumps Hepatitis C
Chicken Pox Hepatitis A  
German Measles Hepatitis B  

What Have We Forgotten to Ask? Please provide in the space below any additional information about the camper's health that you think is important or that may affect the camper's ability to fully participate in the camp program. Attach additional information if needed.

Camper Release Form

To comply with the State of Michigan Law, YMCA Camp Copneconic must have the names of those adults you authorize to pick up your child. Please complete the following information and sign below. We will ask for photo identification at the time of pick up. Please list all adults authorized to pick up your child including yourself.

I give permission for (Camper's Name) to be released to:

at the end of camp or should an emergency arise where my child has to leave camp.
Check This Box To Electronically Sign This Release Form.

Please select a security word to be used in the event that the people listed above cannot pick up your child from camp. Both you and the person picking up the child will be asked to confirm the security word. Please contact the camp office before check out if this occurs.
Security Word:

Authorization For Audio/Visual Records

As the Parent/Legal Guardian of I understand that the YMCA may make certain reasonable recording of this camping event. Do you herby authorize the YMCA to have and use reasonable photographs, slides, moving pictures, and audio/video tapes of your child for purposes of legitimate YMCA records, public relations and/or advertising? Yes  No

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