Summer Camp Medical Form

HEALTH RECORD FOR CHILDREN IN DAY CAMPS & AFTERSCHOOL & YOUTH CENTERS

(This side to be filled in by parent/guardian.)

Name of Program:

Child’s Last Name:    Child’s First Name:

Birthdate:    Sex: Male Female

Home Address:

Parent/Guardian:    Phone:

Place of Employment: Parent/Guardian #1:    Work Phone:

Parent/Guardian #2:    Work Phone:

In case of emergency, notify:    Phone:

If Parent, Guardian are not available in an emergency, notify:

Important: Has this camper been exposed to any communicable disease during the three weeks prior to camp attendance? Yes No

If yes, state type of exposure:

HEALTH HISTORY: (Check, giving approximate dates)

Ear Infection:    Hay Fever:    Measles:

Rheumatic Fever:    Ivy Poisoning, etc.:    German Measles:

Convulsion:    Insect Stings:    Mumps:

Diabetes:    Penicillin:    Other Contagious Illnesses:

Behavior:    Other Drugs:

Asthma:    Chicken Pox:

Other Past Illnesses:

Operations or Serious Injuries (Dates) / Hospitalization (Dates):

Chronic or Recurring Illness:

Any specific activities to be encouraged? Conditions that require activity to be restricted?:

Permission for all program activities unless otherwise noted by doctor:

Appliance worn (glasses, contacts, etc.):

Medication taken:

Suggestion from Parent/Guardian:

*****CONSENT FOR EMERGENCY MEDICAL TREATMENT*****

I do hereby give authority to the New York City’s YMCA staff to obtain necessary emergency medical treatment for my child with the understanding that the family will be notified as soon as possible.

Date:    Phone:

PHYSICAL EXAMINATION

(To be filled out by Physician – please note information on opposite page.)

The purpose of this health record is to provide the staff with pertinent information, which will help to serve the needs of this child in YMCA programs.

IMMUNIZATION HISTORY: This is a record of dates of basic immunization and most recent booster doses.

DTaP/Tdap/DTP/Td

Polio

MMR

Haemophilus influenzae type B (Hib)

Hepatitis B

Varicella

Other:

Other:    Date:

MEDICAL EXAMINATION: To be filled out by licensed physician

Examination is acceptable when performed no more than 12 months prior to arrival at camp.

Code: S = Satisfactory      X = Not Satisfactory (Explain)      O = Not Examined

General Appearance:

Height:    Weight:    Blood Pressure:    Hgb. Test (Date):

Urinalysis (Date):    Posture & Spine:    Throat – Tonsils:

Eyes:    Vision:    w/Glasses:    Extremities:

Heart:    Ears:    Hearing:    Feet:

Lungs:    Skin:    Nose:    Teeth:

Abdomen:    Hernia:    Genitalia:

Neurological Findings:

Describe Abnormal Findings and/or Handicapping Conditions:

Has child ever received products containing horse serum?:

Allergy: (Please specify):

Recommendations and restrictions while in camp:

Special Diet:

Special Medicine (name it):

Is parent/guardian sending special medicine?:

Swimming:    Diving:

Activity Restrictions:    General Appraisal:

I have examined the person herein described, reviewed his/her health history and it is my opinion that he/she is physically able to engage in Day Camp/Year Round Afterschool and Youth Center activities, except as noted above.

Physician’s Name (Please Print):

Address:    Zip Code:    Phone:

Doctor’s Stamp Here