Mystic Lake YMCA Camp

HEALTH HISTORY FORM

This should be filled in by parents/guardian of minors

Dates Attending_________________________________________________________

Name___________________________________________________________________________________________Birth Date_______________________ Age____________________________________

Name___________________________________________________________________________________________Session Dates____________________________________________________________

Home Address_____________________________________________________________________________________________________________________________________________________________
City_____________________________________________________________________________________________State_____________________________ Zip_____________________________________
Gender:

Male

Female

Custodial Parent/Guardian___________________________________________________________________________________________________ Phone_________________________________

Home Address (if different from above)__________________________________________________________________________________________________________________________________
City_____________________________________________________________________________________________State_____________________________ Zip_____________________________________
Business Address_______________________________________________________________________________________________________________ Phone_________________________________
City_____________________________________________________________________________________________State_____________________________ Zip_____________________________________
Second parent or guardian or emergency contact
Name_______________________________________________________________________________________________________________________________ Phone_________________________________
Address______________________________________________________________________________________________________________________________________________________________________
City_____________________________________________________________________________________________State_____________________________ Zip_____________________________________
If not available in an emergency notify:
Name_________________________________________________________________________________________________________________________________________________________________________
Relationship______________________________________________________________________________________________________________________ Phone_________________________________
Address______________________________________________________________________________________________________________________________________________________________________
City_____________________________________________________________________________________________State_____________________________ Zip_____________________________________
Insurance Information (Please provide a copy of your insurance card)
Is the participant covered by family medical/hospital insurance?

Yes

No

If so, indicate carrier or plan name_____________________________________________________Group #____________________________________________________________________

Carrier Address____________________________________________________________________________________________________________________________________________________________
Name of Insured_____________________________________________________________________________Relationship to Participant___________________________________________
Policy Holder Insurance ID Number__________________________________________________________________________________________________________________________________

Important - This box must be complete for attendance

Permission to Provide Necessary Treatment or Emergency Care: I hereby give permission to the medical personnel selected by
the camp director or designated staff member to order x-rays, routine tests, treatment; to release any records necessary for
insurance purposes; and to provide or arrange necessary related transportation for me/or my child. In the event I cannot be
reached in an emergency, I hereby give permission to the physician selected by the camp director or designated staff member
to secure and administer treatment, including hospitalization, for the person named above. My child and I have reviewed and
agree to the camper Behavior Policy found on page 8 of the Mystic Lake Camp Parent Handbook.
Signature of parent or guardian or adult camper/staff_________________________________________________________________________________________________
Witness____________________________________________________________________________________________________________________________ Date___________________________
I also understand and agree to abide by the restrictions placed on my camp activities.
Signature of minor or adult camper/staff_________________________________________________________________________________ Date___________________________
This health history is correct and complete as far as I know, and the person herein described has permission to engage in all
camp activities except as noted.

Health History Form - Page 1

THE FOLLOWING INFORMATION MUST BE FILLED IN BY THE PARENT/GUARDIAN, OR ADULT CAMPER OR STAFF
MEMBER. THE INTENT OF THIS INFORMATION IS TO PROVIDE APPROPRIATE CARE. KEEP A COPY OF THE COMPLETED
FORM FOR YOUR RECORDS. ANY CHANGES TO THIS FORM SHOULD BE PROVIDED TO CAMP HEALTH PERSONNEL
UPON PARTICIPANTS ARRIVAL TO CAMP. PROVIDE COMPLETE INFORMATION SO THAT THE CAMP CAN BE AWARE OF
YOUR NEEDS.

ALLERGIES LIST ALL KNOWN.

DESCRIBE REACTION AND MANAGEMENT

OF THE REACTION.

Medication allergies (list)

_____________________________________________________________________

____________________________________________________________________________________________________

_____________________________________________________________________

____________________________________________________________________________________________________

Food allergies (list)

_____________________________________________________________________

____________________________________________________________________________________________________

_____________________________________________________________________

____________________________________________________________________________________________________

Other allergies (list)

_____________________________________________________________________

____________________________________________________________________________________________________

_____________________________________________________________________

____________________________________________________________________________________________________

MEDICATIONS BEING TAKEN

This person takes NO medications on a routine basis.

This person takes medications as follows:

Med #1___________________________________________Dosage________________Specific times taken each day___________________________________________________
Reason for taking_________________________________________________________________________________________________________________________________________________
Med #2__________________________________________Dosage________________Specific times taken each day___________________________________________________
Reason for taking_________________________________________________________________________________________________________________________________________________
Med #3__________________________________________Dosage________________Specific times taken each day___________________________________________________
Reason for taking_________________________________________________________________________________________________________________________________________________
Attach additional pages for more medications.
Identify any medications taken during the school year that participant may not take during the summer:
________________________________________________________________________________________________________________________________________________________________________

DIETARY RESTRICTIONS THE FOLLOWING RESTRICTIONS APPLY TO THIS INDIVIDUAL:

Does not eat red meat

Does not eat pork

Does not eat eggs

Does not eat poultry

Does not eat seafood

Does not eat dairy products

Other (describe)_______________________________________________________________________________________________________________________________________________________

Health History Form - Page 2

Explain any restrictions to activity (e.g. what cannot be done, what adaptations or limitations are necessary)

________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________

GENERAL QUESTIONS (EXPLAIN YES ANSWERS BELOW.)

Has/does the participant:
1. Had any recent injury, illness or
infectious disease?
2. Have a chronic or recurring illness?
3. Ever been hospitalized?
4. Ever had surgery?
5. Have frequent headaches?
6. Ever had a head injury?
7. Ever been knocked unconscious?
8. Wear eyeglasses, contacts or
protective eye wear?
9. Ever had frequent ear infections?
10. Ever passed out during or after
exercise?
11. Ever been dizzy during or after
exercise?
12. Ever had seizures?
13. Ever had chest pain during or after
exercise?
14. Ever had high blood pressure?
15. Ever been diagnosed with a heart
murmur?
16. Ever had any back problems?

Yes No

Yes No
17. Ever had problems with joints
(e.g., knees, ankles)?
18. Have an orthodontic appliance
being brought to camp?
19. Have any skin problems?
20. Have diabetes?
21. Have asthma?
22. Had mononucleosis in the past
12 months?
23. Had problems with
diarrhea/constipation?
24. Have problems with sleepwalking?
25. If female, have an abnormal
menstrual history?
26. Have a history of bed-wetting?
27. Ever had an eating disorder?
28. Ever had emotional or mental difficulties
for which professional help was sought?
29. If female, has she had her first period?
30. If no, have you discussed with her?
31. Has your child broke any bones in
the last year? If yes, which bone &
Date it Broke.

Please explain any yes answers, noting the number of the questions.
________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________
Which of the following
Has the participant had?
Measles
Chicken Pox
German measles
Mumps
Hepatitis
TB Mantoux Test
Date of last test_______________
Result:
Positive
Negative

Please give all dates of immunization for:

Vaccine Dates:
Mo/Yr Mo/Yr
DTP
_ ___________ ____________
TD (tetanus/diphtheria)
_ ___________ ____________
Tetanus
_ ___________ ____________
Polio
_ ___________ ____________
MMR
_ ___________ ____________
or Measles
_ ___________ ____________
or Mumps
_ ___________ ____________
or Rubella
_ ___________ ____________
Haemophilus influenza B _ ___________ ____________
Hepatitus B
_ ___________ ____________
Varicella (chicken pox)
_ ___________
BCG
_ ___________
Health History Form - Page 3

Mo/Yr Mo/Yr
____________ ___________
____________ ___________
____________ ___________
____________ ___________

____________
____________

Mo/Yr
___________
___________
___________
___________

Mo/Yr
____________
____________
____________

Use this space to provide any additional information about the participants behavior and physical, emotional, or
mental health about which the camp should be aware.
________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________
Before your child comes to camp, please take a moment to check him/her for head lice. This parasite is very
transferable to other children and can pose a real problem at camp.
Name of Family physician_______________________________________________________________________________________Phone________________________________________________
Address______________________________________________________________________________________________________________________________________________________________________
Name of Family dentist/orthodontist________________________________________________________________________Phone________________________________________________
Address______________________________________________________________________________________________________________________________________________________________________
Date of Last Physical_____________________________________________________________
My child is physically and emotionally able to participate in all camp activities without limitation:

Yes

No

If no, please explain activity restrictions:________________________________________________________________________________________________________________________

SPECIAL NEEDS
Does your child have special needs? If yes, what advice can you provide us with in handling your childs special needs?
Please be specific:________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________

PARENTAL TIPS
What method of working with your child gets the best results from you at home?
________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________
What should the camp counselor know about your child in working with him/her this summer?
________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________

AUTHORIZATION TO RELEASE

Names of persons other than parent to whom child may be released:

1._____________________________________________________________________________________ 3.______________________________________________________________________________________
2._____________________________________________________________________________________ 4.______________________________________________________________________________________
Signature of parent or guardian_____________________________________________________________________________________ Date___________________________________________

TRANSPORTATION/FIELD TRIPS

I hereby give my permission to Mystic Lake Camp for my child to be transported in a vehicle and/or participate in field trips and for
visits to the doctor office, urgent care or emergency room for care.
Signature of parent or guardian_____________________________________________________________________________________ Date___________________________________________
Health History Form - Page 4