Youth Health Form      
YMCA STORER CAMPS 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
Father/Guardian Name Father/Guardian Home Phone Father/Guardian Work Phone Father/Guardian Cell Phone
Mother/Guardian Name Mother/Guardian Home Phone Mother/Guardian Work Phone Mother/Guardian Cell Phone
Emergency Contact Name Emergency Contact Home Phone Emergency Contact Work Phone Emergency Contact Cell Phone
Medication Information

“Medication” is any substance a person takes to maintain and/or improve his/her health. Includes vitamins and homeopathic remedies.

This camper will take the following daily medication(s) while attending YMCA Storer Camps.

Please bring enough of each medication to last their entire stay. ALL medications must arrive in appropriately labeled pharmacy containers as described in the Health Services Parent Information.

Name of Medication Reason for Taking It When Given Dosage Date Started
Breakfast
Lunch
Dinner
Bedtime
Other
Breakfast
Lunch
Dinner
Bedtime
Other
Breakfast
Lunch
Dinner
Bedtime
Other
Breakfast
Lunch
Dinner
Bedtime
Other

The Health Center stocks the following over-the-counter (OTC) medications and remedies; do not send these with your camper. Health Officers have medical protocols from the camp physician which directs the use of these medications for common and routine human health problems.

Please select the medications that your camper should NOT be given:

Acetaminophen (Tylenol) Diphenhydramine (Benadryl) Chloraseptic Spray (Sore Throat)
Ibuprofen (Motrin, Advil) Docusate Sodium (Stool Softner) Tums
Pseudoephedrine (Sudafed) Loperamide HCL (Anti-Diarrhea) Cough Drops
Guaifenesin DM (Cough Medicine) Silver Sulfadiazine Calagel
TechNu Extreme (Poison Ivy) Hydrocortisone Cream  
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  
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
Allergies Nutrition
This camper has no known allergies

Has a food allergy? Yes: No:

Contact required to cause allergy:
Ingestion Contact Airborne

Causes anaphylaxis? No   Yes

Describe their reaction and how it is managed:


Has a medication allergy? Yes: No:

Causes anaphylaxis? No   Yes

Describe their reaction and how it is managed:


Has other allergies: Yes: No:

Causes anaphylaxis? No   Yes

Describe their reaction and how it is managed:

Our kitchen prepares well-balanced meals. We can work with some medically prescribed diets but do not cater to individual food preferences.

This camper eats a regular diet

This camper is the following type of vegetarian:

Semi-vegetarian (no pork or beef)
Pesco (no pork, beef or chicken)
Lacto-ovo (no pork, beef, chicken, seafood or fish)
Vegan (no meats, seafood, eggs or dairy)
This camper does not eat pork because of faith reasons.
This camper is gluten-intolerant.
This camper is lactose-intolerant.

Please provide any information if necessary:

 

Please call us at 517.536.8607 if you have questions pertaining to your camper’s dietary needs.

 

Health History

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


My camper is free from illness, injury, physical challenges or health concerns that would affect participation in programming.

The following is true for my camper:  
Anaphylaxis* Frequent Ear Infection GIRLS ONLY: Knows about menstruation and/or has regular menstrual history
Asthma* Frequent Headaches
Diabetes* Has Glasses/Contacts GIRLS ONLY: Menstrual Cramps
ADD/ADHD Had Chicken Pox/Varicella Immunization Recent Illness:
Autism Hearing Impairment Recent Injury:
Bedwetting Head Injury Recent Hospitalization:
Bleeding/Clotting Heart Defect/Disease Recent Surgery:
Chronic Illness Homesickness Other
Please Describe:
Diarrhea/Constipation Psychiatric Treatment/Counseling
Eating Disorder Seizure Disorder
Emotional Health Concern Sleepwalking
Fainting Skin Problems
Frequent Colds Surgical History of Consequence
If you checked Anaphylaxis, Asthma or Diabetes you will have to fill out a form for each of those checked items after completing this health form. A link will be provided once this form is completed.

Please give more information about checked items above.

If your camper has had a significant life event that continues to affect the camper’s life, please provide information about the event, its impact upon your camper’s life and care tips for their time at camp.

What Else Would You Like Us To Know? Let us know any information about your camper’s health that may have not been covered on this form. Any information that has an impact on your child’s ability to fully participate in our program is appreciated.


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:

Additional Information
We at YMCA Storer Camps want your child to have the best camp experience possible. The more information you are able to give, the better prepared we are to work with your child. Please contact us at (517) 536-8607 if you would like to discuss any concerns.


Please tell us a little about your camper:

  Never Sometimes Often Always
Often laugh or smile?
Adjust well to change?
Like group activities?
Have variations in mood?
Become easily Frustrated?
Seem sensitive to criticism
Seem difficult to motivate?
Socialize well with their peers?

What goals do you hope your camper to reach at camp?

What activities does your camper enjoy?


Is there anything your camper has a tendency to be afraid or anxious about?

In the case of behavior or conflict, how can we best help your camper to be successful and resolve situations?

Thank you filling out this health form. If you checked anaphylaxis, asthma or diabetes please fill out the appropriate form on the next page after clicking submit.