YMCA STORER CAMPS: SUMMER CAMP YOUTH HEALTH FORM
NOTE: Please complete and submit application via desktop computer or iPhone. Digital health form is currently not compatible with Android smartphone devices.
Fields in pink are required
Personal Information
Member ID: You should have been issued a member ID for your camper when you registered.
Camper Last Name: Camper First Name: Middle Initial:
Birthday: Age: Village/Program: Session:
Gender: Height: ft inches     Weight:
Street Address:
City: State: Zip: Country
Emergency Contact Information
Parent/Guardian Name Relationship to Camper Parent/Guardian Phone Parent/Guardian Work Phone
Parent/Guardian Name Relationship to Camper Parent/Guardian Phone Parent/Guardian Work Phone
Alternate Contact Name Relationship to Camper Alternate Contact Phone Alternate Contact Work Phone
Medication Permission

Our Health Center is stocked with medications used to manage illness and injury as directed by our medical protocols.
A list of our stocked medications can be found at here.
Please list any medications that your camper should NOT be given:

Medication Information

““Medication” is ANY substance used to maintain and/or improve an individual’s health, including vitamins and ointments.

Per Michigan state law, medications must meet the following standards:
Medication must arrive in its original packaging. Medication will only be administered in age-appropriate doses according to the medication label or a signed physician’s note. Medication cannot be expired, per the expiration date on the medication container.

Please note:  

  1. Campers are expected to carry their emergency medications (epinephrine injectors, rescue inhalers and diabetic supplies) on their person, while at camp. All other medications, including vitamins and ointments, must be stored at our Health Center.
  2. Our Health Center is stocked to manage illness and injury as directed by our medical protocols. Campers do not need to bring a personal supply of Tylenol, Ibuprofen, Benadryl, Tums, Sudafed, Cough Drops, Hydrocortisone or Antibiotic Ointment to camp.

Please list ALL medications your camper will be bringing to camp.

Medication Name and Strength Reason for Taking It When Given Dosage Year
Started
Breakfast
Lunch
Dinner
Bedtime
Other
Only as Needed
Breakfast
Lunch
Dinner
Bedtime
Other
Only as Needed
Breakfast
Lunch
Dinner
Bedtime
Other
Only as Needed
Breakfast
Lunch
Dinner
Bedtime
Other
Only as Needed
Insurance Information
Please include a copy of your insurance card, both front and back sides.

If additional medical care for your child is necessary, the hospital will need the copy of your insurance card in order to bill your insurance provider.

YMCA Storer Camps does NOT carry health/accident insurance for campers, schools, and conference camping participants.

Primary Policy Holder Insurance Company Policy Number Relationship to Child
Physician's Name Physician's Phone Number Date of Last Visit  

Can you scan or take a picture of the front and back of your insurance card and upload now? This will save time at check-in.


If you are unable to upload at this time, you may fax the requested documents to 517-536-4922, email the the document to storer@ymcastorercamps.org or bring a copy to check-in.

Immunizations

Provide the month and year for each immunization. Starred (*) immunizations must be current.
I have chosen NOT to immunize my child.

Immunization Date: Month/Year Immunization Date: Month/Year
Tetanus Booster * (Within 10 years) Meningitis
Polio * Pertussis Booster (Whooping Cough)
MMR (Measles, Mumps, Rubella) * Pneumoccocal
DPT (Diphtheria, Tetanus, Pertussis) * Hepatitis A
Varicella (Chicken Pox) Hepatitis B
Influenza

Can you scan or take a picture of your camper's immunization record? This will save time at check-in.


If you are unable to upload at this time, you may fax the requested documents to 517-536-4922, email the the document to storer@ymcastorercamps.org or bring a copy to check-in.

Allergies
This camper has no known allergies

Has a food allergy? Yes: No:

Causes anaphylaxis? Yes No  

Anaphylaxis caused by:
Ingestion Contact Airborne

Describe their reaction and how it is managed:


Has a medication allergy? Yes: No:

Causes anaphylaxis? Yes No  

Describe their reaction and how it is managed:


Has other allergies: Yes: No:

Causes anaphylaxis? Yes No   

Describe their reaction and how it is managed:

Nutrition

Our kitchen prepares well-balanced meals. 

We work with dietary concerns but do not cater to individual food preferences.

Please call us at 517-536-8607 if you have questions pertaining to your camper’s dietary needs.

This camper has no dietary restrictions

This camper has the following dietary restrictions:

No beef
No pork
Vegetarian (no meats or seafood)
Vegan (no meats, seafood, eggs or dairy)
Gluten-intolerant.
Lactose-intolerant.

Please provide any information if necessary:

Health History

Please check those that pertain to your camper and describe how it is handled at home.

The following is true for my camper: Recent Injury
Asthma* Hearing Impairment Traveled Outside the United States (within last year)
Diabetes* Head Injury Vision Concern
ADD/ADHD Heart Condition Recent Illness
Autism Homesickness Recent Surgery
Bedwetting Mental Health Concern Recent Hospitalization
Bleeding Disorder Menstruation Issues Other
Chronic Illness Migraines Please Describe:
Chronic Pain/Injury Mobility Issues
Diarrhea and/or Constipation Seizure Disorder
Eating Disorder Sleepwalking
Fainting Skin Issues None of the Above

Please give details about checked items and note if your camper has any activity restrictions due to their health history. If you would like to discuss a special concern with our Summer Programs Director, please call 517-536-8607.


Parent/Guardian Authorization

The information contained in this form is correct, as far as I know, and the child herein described has permission to engage in all camp activities except as noted.  I understand that health/accident insurance coverage is the responsibility of the parent/guardian.  I hereby give permission to YMCA Storer Camps to secure emergency medical, routine medical, surgical treatment, and non-surgical care for the child named on this form, while at camp.  I also understand that the parent/guardian is fully responsible for the camper’s transportation if he/she is dismissed for disciplinary, behavior or medical reasons.  I absolve the YMCA of Greater Toledo/Storer Camps and all of its employees of any and all liability, financial and/or otherwise arising from administration of medication to my child under the terms of this release.  YMCA Storer Camps is not responsible for payment of any medical expenses incurred during participation at camp.
In consideration for being allowed to participate in the YMCA’s programs, I agree to assume the risk of such activities and programs, and I further agree to hold harmless the YMCA of Greater Toledo, it’s officers, employees and representatives from any and all claims, suits, losses, or related causes of action for damages, including, but not limited to, such claims that may result from injury or death, accident or otherwise, during or arising in any way from the activities.  I grant permission for me or my child to participate in all planned camp activities including out of camp trips by van or bus, hiking or horseback riding.  The YMCA is not responsible for lost, stolen or damaged personal articles.  I also authorize the YMCA to have and use photographs, slides or video tapes of me, my child, or my family as may be needed for its public relations programs.  I acknowledge that this General Release of Liability and Authorization for Treatment of the YMCA is binding on me personally and on my heirs, personal representatives, successors and assigns.

Limited Purpose Power of Attorney: Consent to Treatment of Minor (Must be signed by parent or legal guardian)

By digital signature(s) below, the undersigned appoints YMCA Storer Camps, to act alone, or delegate to another person, the power to consent on our behalf to all emergency treatment and/or medical care (except elective surgery) of (child’s name) determined to be necessary or desirable by our child’s attending physician at the hospital. This Power of Attorney shall continue through the participant’s stay at camp, or until revoked by the undersigned, whichever is earlier. Physicians or the hospital’s medical staff may assume and rely on this authorization being current and in effect during such period unless notified otherwise.

The undersigned certify that they read this Power of Attorney (or had it read to them), that they understand this Power of Attorney, and sign it voluntarily. This agreement will be enforced in accordance with the law of the State of Michigan.

ATTENTION – PLEASE READ THE FOLLOWING CAREFULLY. THIS WAIVER AFFECTS YOUR LEGAL RIGHTS.

I UNDERSTAND THAT CLICKING THIS BOX IS THE EQUIVALENT OF MY SIGNATURE AND DEMONSTRATES ACCEPTANCE OF THE ABOVE TERMS IN THEIR ENTIRETY.

Parent/Guardian Name:    Date:
Your e-mail address: