Camper Health History Form Dates will attend camp: from to Camper name: (first) (middle) (last) Male Female Birth Date Age on arrival at camp: Camper Home Address: Street Address City State Zip Code Parent/guardian with legal custody to be contacted in case of illness or injury: Relationship: Name: to Camper: Preferred Phones: ( ) ( ) Email: Home Address: (If different from above) Street Address City State Zip Code Second parent/guardian or other emergency contact: Relationship: Name: to Camper: Preferred Phones: ( ) ( ) Email: Additional contact in event parent(s)/guardian(s) can not be reached: Relationship: Name(s): to Camper: Preferred Phones: ( ) ( ) Allergies: No known allergies. This camper is allergic to: Food Medicine The environment (insect stings, hay fever, etc.) Other (Please describe below what the camper is allergic to and the reaction seen.) Diet, Nutrition: This camper eats a regular diet. This camper eats a regular vegetarian diet. This camper has special food needs. (Please describe below.) Restrictions: I have reviewed the program and activities of the camp and feel the camper can participate without restrictions. I have reviewed the program and activities of the camp and feel the camper can participate with the following restrictions or adaptations. (Please describe below.) Medical Insurance Information: This camper is covered by family medical/hospital insurance Include a copy of your insurance card if appropriate; copy both sides of the card so information is readable. Insurance Company Policy Number Subscriber Insurance Company Phone Number ( )
General Health History: Check "Yes" or "No" for each statement. Explain Yes answers below. Has/does the camper: 1. Ever been hospitalized? 2. Ever had surgery? 3. Have recurrent/chronic illnesses? 4. Had a recent infectious disease? 5. Had a recent injury? 6. Had asthma/wheezing/shortness of breath? Yes No 7. Have diabetes? 8. Had seizures? 9. Had headaches? 10. Wear glasses, contacts, or protective eyewear? 11. Had fainting or dizziness? 12. Passed out/had chest pain during exercise? Yes No 13. Had mononucleosis ("mono") during the past 12 months? 14. If female, have problems with periods/menstruation? 15. Have problems with falling asleep/sleepwalking? 16. Ever had back/joint problems? 17. Have a history of bedwetting? 18. Have problems with diarrhea/constipation? Yes No 19. Have any skin problems? 20. Traveled outside the country in the past 9 months? Please explain Yes answers in the space below, noting the number of the questions. For travel outside the country, please name countries visited and dates of travel. Mental, Emotional, and Social Health: Check "Yes" or "No" for each statement. Has the camper: 1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)? 2. Ever been treated for emotional or behavioral difficulties or an eating disorder? 3. During the past 12 months, seen a professional to address mental/emotional health concerns? 4. Had a significant life event that continues to affect the camper s life? (History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others) Please explain Yes answers in the space below, noting the number of the questions. The camp may contact you for additional information. In addition to these health forms, I have attached a copy of my child s school physical, to include shot record, with a doctor s signature. Parent/Guardian Authorization for Health Care: This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a "need to know" basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of my child s health record from providers who treat my child and these providers may talk with the program s staff about my child s health status. Signature of Custodial Parent/Guardian: Date: Relationship to Camper: If for religious or other reasons you cannot sign this, contact the camp for a legal waiver which must be signed for attendance.
Medication Form Camper s Name Session Please complete this form prior to coming to camp. Bring it with you to check in. If you have multiple medications please put them together in a zip lock bag with your child s name on the outside of it. Prescription Medications Type of Medication (Name should be the same on the medication container) Time of Day (Breakfast, Lunch, Dinner, Bedtime, or specific time) Dosage (mg / 1 tab / ½ tab) This should be the same on the medication container PRN Medication (taken only as needed) Type of Medication (Name should be the same on the medication container) Time of Day (Breakfast, Lunch, Dinner, Bedtime, or specific time) Dosage (mg / 1 tab / ½ tab) This should be the same on the medication container Over the Counter Medications (Permission Letter) I,, hereby give permission for Camp Kekoka staff to administer over-the-counter medications to my child if they deem it necessary. Dosages will be administered according to the directions on the bottle unless a physician directs otherwise. These medications may include, but are not limited to: Acetaminophen (Tylenol) Ibuprofen (Advil, Motrin) Tums Benadryl Imodium AD Claritin Sudafed PE Generic Cough Drops Aloe Pepto-Bismol Ex-Lax Exceptions (not to be given) Signature Date
Camp Kekoka Activity Parent Sign Off At Camp Kekoka we have lots of activities for your child to enjoy! Please know that safety is at the forefront of everything we do. Please mark through any activity that you would prefer your child not participate in. Water activities we do a swim test on Sunday night. Children must pass the test in order to swim in the deep end of the pool and be eligible to take the knee boarding, skiing, & wakeboarding track time. At the waterfront everyone is required to wear a, coast guard approved, lifejacket at all times. No one is allowed on the waterfront or in the pool unless there is a lifeguard on duty. Staff will make sure lifejackets are the right size and on correctly. Water activities include: kayaking, canoeing, peddle boating, swimming, crabbing, seining, fishing, tubing, sailing, windsurfing, knee boarding, skiing, wake boarding, pool. Land activities include: arts & crafts, drama, recreation center, garden time, big games, sports, slip-n-slide, archery, air riflery, campfires, geocaching, bocce ball, badminton, cooking, dance, & talent show. Should you chose to mark through an activity please have a preemptive conversation with your child before arriving at camp. If you have any questions about any of the above activities please feel free to call. By signing this document you are allowing your child to participate in all of the above activities with the exception of those you marked through. Camper Name Parent Signature Date
Informed Consent and Liability Release Challenge Course YMCA / APYC Camp Kekoka Welcome to our Challenge Course program! The Challenge Course is a powerful outdoor experience designed to foster self-discovery, confidence, teamwork, communication and group process skills. The Challenge Course program is a carefully structured, graduated series of elements incorporating physical, mental and social challenges. Activities may include reliance on others or equipment, climbing over obstacles, walking on cable bridges or riding on the Zip Wire! We are confident your child will find it a great learning experience. Both fun and challenging. When working outdoors and leading physical activities, safety is our main concern. We will regularly discuss basic rules of safety and provide the special organization, supervision, instruction and equipment you need to participate safely in course activities. It is impossible for us to eliminate all risk, however, and your child s commitment to follow instructions and use sound personal judgement will contribute greatly to your well-being. In order to participate in the Challenge Course closed toe & closed heel shoes must be worn. Please ensure your child has a pair so they won t miss out on the fun. I am aware and understand that participating in the Challenge Course, involves a potential risk of physical injury and I understand that the programs are physically demanding and potentially dangerous. I hereby agree and hereby state that I am solely responsible for my own participation and for my own physical and emotional well-being. I am aware and understand that all of the program activities are strictly voluntary and that it is my own choice to participate in each activity to whatever degree I deem appropriate, after due consideration of my own physical health, physical abilities and mental condition. I further state that in choosing to participate, I am not under the influence of any chemical substance including alcohol. I willingly and knowingly assume for myself, my heirs, family members, executors, administrators and assigns all risk of physical injury and emotional upset which may occur during or after participating in any aspect of the program and hereby agree to hold the Peninsula Metropolitan YMCA YMCA / APYC Camp Kekoka, its employees, its instructors, facilitators and agents harmless for any liability arising out of my participation of the program. Should the Peninsula Metropolitan YMCA YMCA / APYC Camp Kekoka or anyone acting on its behalf be required to incur attorney s fees and cost to enforce this agreement, I agree to indemnify and hold the Peninsula Metropolitan YMCA YMCA / APYC Camp Kekoka harmless for all such fees and cost. This release does not, however, apply to any physical injury or emotional harm caused by negligence or willful misconduct of the Peninsula Metropolitan YMCA YMCA / APYC Camp Kekoka, its employees, its instructors, facilitators and agents. I have had sufficient opportunity to read this entire document. I have read and understand it, and I agree to be bound by its terms. (Please see next page for camper information) CAMPER INORMATION Name (please print): Age: Birth Date: Parent or guardian must fill in information & sign below. Parent / Guardian Name (please print): Signature: Date:
Peninsula Metropolitan YMCA Mission, Values, and Behavior Expectations Admission to Camp Kekoka carries many privileges and responsibilities. Attached to this packet is the Mission & Values Based Compass of the Peninsula Metropolitan YMCA. At Camp Kekoka everyone is expected to uphold the mission and behaviors associated with each value. Please take the time to read it over and understand the behavior expectations of each participant. Your signatures below signify understanding and acceptance of these expectations. Should a behavior or discipline problem affect our work with the other participants or their enjoyment of Camp Kekoka, we reserve the right to dismiss those campers responsible, without refund. Furthermore it is the responsibility of the parent to pick up their child within 2 hours of being dismissed. Parent/Legal Guardian s Signature: Date: I agree to abide by the rules and policies of the YMCA and conduct myself as an exemplary representative of my YMCA Junior Leaders Club. Camper s Signature: Date: