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    Current Medications (Special Needs/Disabilities (Please Complete The Attached Individualized Care Plan Form)

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    ymcawnc
    1) This document is a youth information form for the 2012-2013 YMCA Hendersonville Winter Break Camp program. It collects information about a child such as name, address, birthdate, medical information, emergency contacts, and expectations for the camp. 2) The form requests details about the child's allergies, medications, special needs, interests, and swimming ability. Family information is also collected including parents' names, addresses, phone numbers, and email addresses. 3) In case of an emergency, the form asks for a child's doctor and dentist contact information as well as hospital preference and insurance information. Authorized emergency pick-up contacts are also listed.

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    Download as PDF, TXT or read online from Scribd

    Current Medications (Special Needs/Disabilities (Please Complete The Attached Individualized Care Plan Form)

    Uploaded by

    ymcawnc
    12 views1 page
    1) This document is a youth information form for the 2012-2013 YMCA Hendersonville Winter Break Camp program. It collects information about a child such as name, address, birthdate, medical information, emergency contacts, and expectations for the camp. 2) The form requests details about the child's allergies, medications, special needs, interests, and swimming ability. Family information is also collected including parents' names, addresses, phone numbers, and email addresses. 3) In case of an emergency, the form asks for a child's doctor and dentist contact information as well as hospital preference and insurance information. Authorized emergency pick-up contacts are also listed.

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    1) This document is a youth information form for the 2012-2013 YMCA Hendersonville Winter Break Camp program. It collects information about a child such as name, address, birthdate, medical information, emergency contacts, and expectations for the camp. 2) The form requests details about the child's allergies, medications, special needs, interests, and swimming ability. Family information is also collected including parents' names, addresses, phone numbers, and email addresses. 3) In case of an emergency, the form asks for a child's doctor and dentist contact information as well as hospital preference and insurance information. Authorized emergency pick-up contacts are also listed.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    12 views1 page

    Current Medications (Special Needs/Disabilities (Please Complete The Attached Individualized Care Plan Form)

    Uploaded by

    ymcawnc
    1) This document is a youth information form for the 2012-2013 YMCA Hendersonville Winter Break Camp program. It collects information about a child such as name, address, birthdate, medical information, emergency contacts, and expectations for the camp. 2) The form requests details about the child's allergies, medications, special needs, interests, and swimming ability. Family information is also collected including parents' names, addresses, phone numbers, and email addresses. 3) In case of an emergency, the form asks for a child's doctor and dentist contact information as well as hospital preference and insurance information. Authorized emergency pick-up contacts are also listed.

    Copyright:

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    Download as PDF, TXT or read online from Scribd
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    2012 YMCA of WNC Hendersonville Branch

    Winter Break Camp Youth Information Form


    This youth information is effective for the 2012-2013 YMCA Hendersonville Winter Break Camp Program.
    Childs Information
    Childs name________________________________________________________________________
    Address _____________________________________City ____________________ Zip ___________
    ___ Male ___Female

    Birth date _______________Age (as of August 2012) _____ Ethnicity__________

    School child attends _________________________________Grade (as of Aug. 2012) ______________


    Allergies (please be specific and note level of severity, etc.):
    ________________________________________________________________________________
    Current Medications (please note all medications AND complete the Individualized Care Plan if medications will need to be administered at
    the Y program): _________________________________________________________________________________________
    Special Needs/Disabilities (please complete the attached Individualized Care Plan Form):____________________________
    _____________________________________________________________________________________________________
    What activities your child would enjoy while at Winter Break Camp:________________________________________________
    What are your expectations for the Winter Break Program?_______________________________________________________
    Names and Ages of Siblings: ______________________________________________________________________________
    Swimming Ability (check one): ___ Non-Swimmer

    ___ Beginner

    ___ Intermediate

    ___Advanced

    Family Information (List both parents/guardians AND list first the one parent/guardian (completing this form) to contact for
    payments and questions.
    1st Contact Parent/Guardians name _____________________________________ Employer __________________________
    E-mail address ___________________________________________________________________________________
    (please provide the email address that we may use for contacting you)
    Home Address ______________________________________________ City _______________________ Zip _____________
    Home # _________________ Work # ___________________ ext. _____ Mobile # ________________ Pager # __________
    2nd Contact Parent/Guardians name _____________________________________ Employer __________________________
    E-mail address ___________________________________________________________________________________
    (please provide the email address that we may use for contacting you)
    Home Address ______________________________________________ City _______________________ Zip _____________
    Home # _________________ Work # ___________________ ext. _____ Mobile # ________________ Pager # __________

    Emergency Information (If you do not have a Doctor/Dentist, please list Henderson County Health Department or another
    provider of your choice. All information is REQUIRED, including hospital preference.)
    In case of emergency, please contact the following first:
    ____Mother/Guardian ___Father/Guardian
    Childs Doctor ____________________________________________ Doctors Phone # _______________________________
    Childs Dentist ____________________________________________ Dentists Phone # ______________________________
    Hospital Preference _____________________________________________________________________________________
    Insurance Company _____________________________________________ Policy # _________________________________
    Emergency Contact Information When a parent/guardian is not available, I authorize these individuals to pick-up my child:
    1. Name _____________________________ Relationship to child _____________________ Home # __________________
    Work # _____________________ ext. ____ Mobile # __________________ Pager # ________________
    2. Name _____________________________ Relationship to child _____________________ Home # __________________
    Work # _____________________ ext. ____ Mobile # __________________ Pager # ________________
    3. Name _____________________________ Relationship to child _____________________ Home # __________________
    Work # _____________________ ext. ____ Mobile # __________________ Pager # ________________

    4.

    Name _____________________________ Relationship to child _____________________ Home # __________________


    Work # _____________________ ext. ____ Mobile # __________________ Pager # ________________

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