Camp Parent Guide PDF - YMCA of Silicon Valley

YMCA OF SILICON VALLEY | Resident/Travel Camp Health History Form(Complete one form per child - ALL pages - Must be submitted immediately)Fax or email to: YMCA Camp Campbell at 831-338-9486 or redwoods@ymcasv.orgChild’s Name: ______________________________________________________________ o M o F Age (during camp)_______ Birthdate _____ /_____ /_____Address: ____________________________________________________________ Apt.#________ City___________________________ Zip___________________ Grade _________Parent/Guardian 1: ______________________________________________________ Parent/Guardian 2: _______________________________________________________Home Phone #: ____________________________________________________________ Home Phone #: ____________________________________________________________Employed by: ______________________________________________________________ Employed by: ______________________________________________________________Occupation: _______________________________________________________________ Occupation: ________________________________________________________________Business Phone: _________________________________________________________ Business Phone: __________________________________________________________EMERGENCY INFORMATIONName: _____________________________________________________________________________________ Phone: _____________________________________ Relationship: _________________________________Name: _____________________________________________________________________________________ Phone: _____________________________________ Relationship: _________________________________Name: _____________________________________________________________________________________ Phone: _____________________________________ Relationship: _________________________________INFO REQUIRED BY STATE LAWIf you have insuranceHealth Insurance Co.: __________________________________________________________________Policy Number: __________________________________________________________________________Family Physician: ________________________________________________________________________Phone: _____________________________________________________________________________________Family Dentist: __________________________________________________________________________Phone: _____________________________________________________________________________________DPT: _____________________________________Tetanus: ________________________________Oral Polio: _______________________________Medical Information past or present (please check)Allergies & SPECIAL NEEDS (please check)Measles: ______________________________Mumps: _______________________________Rubella: _______________________________Asthmao Yes o No ADD/ADHDo Yes o No Measleso Yes o NoHeart Defect/Disease o Yes o No Head Lice (recent) o Yes o No German Measles o Yes o NoRecent Hospitalization o Yes o No Bed-wettingo Yes o No Psychological Conditions o Yes o NoCurrently under Dr. care o Yes o No Sleepwalkingo Yes o No Celiac disease o Yes o NoSeizureso Yes o No Tuberculosiso Yes o No Migraineo Yes o NoDiabeteso Yes o No Chicken Poxo Yes o No Other Conditions o Yes o NoFor each Yes, please explain: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Hay Fevero Yes o No Bee Stingso Yes oNo Penicillino Yes o NoOak/Ivy Poisoning o Yes o Noo Bee Sting Kit? Other Drugso Yes o NoFoodso Yes o No Other insects or animals o Yes o No Any other allergies? o Yes o NoCurrent Medications to be continued at camp (dosage/frequency): _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Dietary Restrictions? : o Yes o No ____________________________________________________________________________________________________________________________Any reason to restrict full activity including swimming, long hikes, strenuous physical games?: o Yes o NoIf Yes, please explain: ___________________________________________________________________________________________________________________________________________________Non-prescription medications I authorize the following medications to be administered as needed:Tylenol o Yes o No Benadryl o Yes o NoChloraseptic o Yes o No Cough Drops o Yes o NoClaritan/loratedine/antihistamine o Yes o NoPepto BismolIbuprofenVACCINES (APPROX DATE IMMUNIZED)o Yes o Noo Yes o NoNeosporinCalamine Lotiono Yes o Noo Yes o NoCamper's Name: Last_____________________________________________________ First______________________________ Session: ______________________