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Attention parents and guardians:

Attention Parents and Guardians:

Please complete and sign this form. Teachers must return these forms to the Sherman Lake
YMCA prior to the group’s arrival at camp. ALL INFORMATION IS KEPT CONFIDENTIAL.
Sherman Lake YMCA Outdoor Center

To download the Integrated Education overnight information packet please go to the website
1)click on school programs 2)click on programs and activities
3)click on parent packet for overnight school groups

Registration and Health Information Form
School Name: ____________________________________________ Grade:_________
Camper Information:
Name of Student______________________________ Nickname (if any)___________________
Male or Female (please circle one) Age_______________ Birth date______________________
Home address___________________________________________________________________ Custodial Parent______________________________Relationship to camper________________
Phone (_____) ________________Business phone_____________
Email ___________________
In an EMERGENCY, please contact parent listed above or:
Name:__________________________ Phone: ________________Relationship:_____________
Name:__________________________ Phone: ________________Relationship:_____________
Activities and Interests:
What camp activities most interest your camper? ______________________________________
Are there any camp activities that the camper should not participate in? _____________________
Dietary concerns: (Circle only if apply) Diabetic Lactose Intolerance Vegetarian Picky Eater
Behavior concerns: (Circle only if apply) Nervousness Sleep Walking Bedwetting Homesickness Psychiatric

Do you have any specific requests that you hope your camper will learn while at camp? ________
Camper’s swimming ability: (please circle one) Nonswimmer Fair Good Excellent
Additional information/comments for counselor: ___________________________________________
______________________________________________________________________________________

Health Information:

Past and/or present medical conditions: ______________________________________________
______________________________________________________________________________
Allergies: yes____ no____ List____________________________________
Has your child been exposed to a communicable disease in the last three weeks?
yes____ no____ List____________________________
Has your child ever had a seizure yes____ no____ Explain___________________________
Physical limitations or restrictions yes____ no____ List______________________________ Special dietary needs or restrictions yes____ no____ List____________________________ Additional health information, special medical needs, or concerns _________________________ ______________________________________________________________________________ Are your child’s immunizations up to date? yes____ no____ Date of last tetanus shot ____________Date of last physical exam ________________________ Family Physician______________________________ Phone (_____)_____________________ Family Dentist________________________________ Phone (_____)______________________ Orthodontist__________________________________ Phone (_____)______________________ In the case of unexpected aches and pains, may over the counter medications (Tylenol, Motrin, Benadryl, etc.) be given to your camper? ___ yes ___ no Do you have medical insurance? ___ yes ___ no Insurance company name ________________ Policy or certificate # ___________________________Phone (_____) _____________________ Medications: Please send all prescription medication that your child will need at camp, also
including any regularly used over the counter medications. Send only the amount of medication
needed while at camp. Prescription medication bottle must state the current dosage and schedule.
Permission to dispense medication: (Please list all prescription and non-prescription):
1. MEDICATION: ____________________________Dose:____________________________
Days to be given: ______________________________ or circle ONLY AS NEEDED
Circle time to be given: Breakfast Lunch Mid-afternoon Dinner Bedtime
2. MEDICATION: ____________________________Dose:____________________________
Days to be given: ______________________________ or circle ONLY AS NEEDED
Circle time to be given: Breakfast Lunch Mid-afternoon Dinner Bedtime
Parent Signature Required:
This health history is correct to the best of my knowledge, and the person herein described has permission
to engage in all camp activities except as noted. Authorization for Treatment: I hereby give permission to
the medical personnel selected by the camp staff to order X-rays, routine test, treatment, and necessary
transportation for my child or me. In the event I cannot be reached in an emergency, I hereby give
permission to the physician selected by the camp staff to secure and administer treatment, including
hospitalization, for my child or me as named above. These completed forms may be photocopied for trips
out of 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 Sherman Lake YMCA
Camp and its staff members conducting the activities from any and all claims, suits, losses, or related
causes of action for damages, including, but not limited to, such claims that my result from injury or death,
accident or otherwise, during or arising in any way from the activities. I grant permission for my child or
me to participate in all planned camp activities including out-of-camp trips by van or bus, hiking or
horseback riding, understanding that competent leadership is provided. The YMCA is not responsible for
lost, stolen, or damaged personal articles. I also authorize the Sherman Lake 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 of the Sherman Lake YMCA is binding on
me personally and on my heirs, personal representatives, successors, and assigns.
Parent/Staff Signature_____________________________________Date_____________
**Anyone under the age 18 must have a parent signature. Over the age 18: This form enables you to be treated in case of emergency.
***Please note: All School Personnel that plan to attend the Sherman Lake YMCA must fill out and sign this form.

Source: http://www.shermanlakeymca.org/cmsAdmin/uploads/IE-Health-Form.pdf

Nmd21310 807.810

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