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YMCA CAMP PERMISSION & HEALTH FORM

Childs Name

Nickname
Primary Address

City State Zip

Birth Date / /

Age

Grade Entering in the Fall
#1 Parent or Guardians Name

Home Phone
( )
Home Address (if different) (Street, City, State, Zip)

Employed by

Hours of Employment:
From To
Business Phone
( )
Pager or Cell Phone
( )
Email address:

#2 Parent or Guardians Name

Home Phone
( )
Home Address (if different) (Street, City, State, Zip)

Employed by Hours of Employment:
From To
Business Phone
( )
Pager or Cell Phone
( )
Email address:

Contact in Case of Emergency/Pick Up Authorized (Other than Parents)

Name: Relationship #To Be Reached

Name: Relationship #To Be Reached

Additional Authorized Persons for Pick Up

You will be required to sign your child in/out every day. For your childs safety, we require a list of persons (other than the
parents/guardians allowed to pick up your child. (Parent/Guardian #1 & #2 are allowed full pick up privileges unless official
order states otherwise)
ALL PERSONS MUST SHOW A PHOTO ID UPON REQUEST.

Name Phone Relation

Address

Name Phone Relation

Address

Name Phone Relation

Address

* If shared custody, describe custodial information. Copy of court order custody decree must be
attached.

** All lines must be filled out in order for your childs registration to be processed. If an item does not
apply, please write N/A on the line.
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HEALTH HISTORY
Please indicate in the appropriate area if your child had or has any of the following:

Diseases Medical Allergies Adaptive Equipment
Kidney trouble Ear infection Hay fever Glasses
Heart trouble Rheumatic fever Poison ivy Hearing aid
Diabetes Seizures Insect Stings Wheelchair
Physical Disability Penicillin AFOs or crutches
Other Communication
Device

Please describe any reaction your child may have to the above listed allergies:



Does your child have any Chronic Health problems such as asthma, diabetes, severe allergies, etc?
YES NO

If yes, an additional Chronic Health form will be required. Please note your registration will not be
processed until you and your Physician have completed the Chronic Health form.

Please describe your childs chronic or recurring illnesses



Please indicate in the appropriate area if your child has been diagnosed with the following:

ADD DD Cerebral Palsy Rhett Syndrome
ADHD PDD Bipolar Disorder Down Syndrome
Autism ODD Tourette Other
Asberger OCD Fragile X

Does your child have an IEP? YES NO
Does your child have a behavior management plan? YES NO
Does your child have a Section 504 Student Accommodation Plan? YES NO

Please note, you MUST submit a current IEP/BMP/Section 504 Student Accommodation Plan with
this registration form and complete and return the Inclusion Information Forms (available at the
YMCA Service Center) before program participation is authorized. Enrollment will NOT be
considered final until all required processes have been met and reviewed. Although every effort
is made to provide reasonable accommodations, there may be instances where a childs needs
may exceed the parameters of the scope of our program.

Will your child need to be administered prescription medication during the camp day?
YES NO

If yes, please note you MUST complete a medication authorization form on the first day of camp. This
form can be obtained from the camp director. Medicine must be brought in the original container with the
original label, (this includes inhalers). No over the counter medicine will be administered.
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IMMUNIZATION RECORD
I /We certify that our child has received and is current on their immunization records as listed below:
______yes ______no (if no, a copy of the Missouri Immunization Exemption Form must be
attached to complete required paper work prior to camp attendance. Preschool-Age children MUST
have a separate form completed by their physician on file.
Immunizations (variations based upon grade level)
DTP Polio (IPV) MMR Hep B Hep A TDAP Varicella
Meningococcal HPV
If I cannot be reached to make necessary arrangements, or in a critical emergency requiring medical
care, I hereby authorize the YMCA to contact:

The YMCA does NOT provide accident insurance for your child. This will be the responsibility of
the parent.

Doctor/Clinic Name

Address (street, city, state, zip)

Telephone
( ) ext.
Hospital transported to nearest facility.
To be determined by Medical personnel
Address (street, city, state, zip) Telephone
( ) ext.
Insurance Name

Group #

Policy #



Parent Authorization


I verify to the best of my knowledge that everything on the permission and health form is correct and the child
herein is in good health. He/She has no physical ailments that will prevent normal participation unless specified
on this form. He/She has my permission to participate in YMCA summer camp activities. I recognize failure to
disclose, falsification or deliberate omission of information will result in termination of services. I also understand
that it is my childs responsibility to bring and apply his/her own sunscreen. (Please make sure there is no allergy
to the sunscreen whereas it is considered a medication). I understand that in the event of an emergency, my
child will be taken to the closest hospital. I accept responsibility for the charges incurred from transportation,
medical or surgical treatment.

Parent/Guardian Signature Date



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Parent/Guardian Agreement

Please read carefully and sign below.

I understand that I am committing myself to participation in the camp programs.
I understand that I am financially responsible for the services.
I understand that all camp fees will be paid in full by Monday, one week prior to camp attending. I
understand that the YMCA reserves the right to place late registrants in camps where space and/or staff
are available.
I understand that a deposit per session, per camper will be due at the time of registration. I understand
that this deposit is non refundable and cannot be transferred to another camp.
I understand that a $20 change fee will be charged for camp changes. (These changes are subject to
camp availability). A change form MUST be completed and turned into the registrar for change to
happen.
I understand that if my child is not picked up at the end of their camp day on time my account will be
charged a late fee in the amount of $1.00 per minute/per child until my child is picked up.
I understand that when my child is ill it is understood and agreed that he/she may not be accepted to
camp.
I understand that my child will not be released to any person(s) not listed on the camp permission form.
I understand that my child will not be released to any person(s) who seems to be under the influence of
drugs or alcohol.
I understand that my child must be signed in & out daily by myself or my designee (as listed on the
permission form).
If my child is experiencing problems in the program, a conference will be arranged between the parent,
staff and Program Director.
I understand the YMCA Behavior Management Guidelines will be followed and enforced.
The YMCA reserves the right to terminate services if it is determined that the placement is unsatisfactory.
The YMCA is an inclusive, family-friendly organization. We expect all our members, program participants
and guests to model our four values - - caring, honesty, respect, responsibility - - in their conduct and
language. The YMCA has the right to deny applications for individual or family memberships or
participation in programs and to terminate or suspend existing individual or family memberships or
participation in all YMCA programs or activities at our sole discretion if actions or behaviors are not
deemed to be in the best interests of the organization. If a membership or program is terminated or
suspended, all fees already paid will be forfeited. The YMCA has sole discretion to reinstate members
and participation privileges in YMCA programs and activities.
I understand should my child be suspended/dismissed from camp due to behavioral issues, the YMCA
will NOT prorate the weekly camp balance and I will be responsible for the full amount.
The YMCA provides a recreational environment for children and teens with and without disabilities
through added support staff when needed to facilitate successful participation into the programs when
appropriate.
All information I have provided at the time of enrollment is complete and accurate.
I understand that photographs will be taken throughout the camp day. These pictures may be displayed
in YMCA brochures and on the YMCA website. If I do not want my childs picture taken, I understand it is
my responsibility to notify the YMCA Camp Office.
I agree that my child may take part in any special activity or trip with the YMCA. It is my understanding
that advance notice will be given and that all activities will be supervised.
I have received, read and agree to abide by all the policies, procedures, and fee requirements as outlined
in the parent handbook.

Parent/Guardian Signature: Date
Revised 12/2010