Camp Meskwaki Health & Safety Form

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Please answer ALL questions below. All information is confidential and for Camp Meskwaki Staff ONLY.

Email *

Child's Name *

Physician Information - Name, Address, Hospital/Clinic, & Phone Number *

In case of an emergency or sudden illness, I hereby give authority to any hospital/doctor to render care to my child(ren). *

Yes

Is your child(ren) allergic to anything? (bee stings, food, medications, etc.) - Answer Yes or No - If Yes, please explain *

Are there any health conditions/physical problems that would impair your child(ren)’s activity? - Answer Yes or No - If Yes, please explain *

Does your child(ren) have ADD, ADHD, or any type of behavioral disorder we should be aware of? - Answer Yes or No - If Yes, please explain *

Does your child(ren) have any speech problems? - Answer Yes or No - If Yes, please explain *

Are there any special diet requirements or other special instructions? - Answer Yes or No - If Yes, please explain *

Tetanus Immunizations - Dates & Booster Dates *

Name of Medication, Medication Dosage, Reason for taking Medication, & Time to Distribute Medication. Type N/A if there is no medication that needs to be distributed. *

Time Medication Needs To Be Distributed. Type N/A if there is no medication that needs to be distributed. *

I hereby give permission for my child(ren), to take medication while attending Camp Meskwaki, under the supervision of authorized YMCA personnel. *

Yes

No Medication Needed to be Distributed

Required

Parent/Guardian Signature *

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