YMCA CAMP MANITOU-LIN
CONFIDENTIAL HEALTH AND RELEASE FORM

We ask that you give us some rather detailed information that will help our staff to best provide programs and supervision for your child. The information will be reviewed and passed on to your child’s counselor. You know your camper best and your answers will help us provide the best possible experience. The intent of this information is also to provide camp health care personnel the background to provide appropriate care. Please provide complete information so that we can be aware of your needs.

Overnight Camp Teen Overnight Camp Horse Overnight Camp Day Camp Kinder Day Camp Teen Day Camp Horse Day Camp Date/Week #:
Campers Name
First Last
Age at Camp:
Nickname (if any)
Birth date: (m/d/year):
Home Address:
City:
State:
Zip:

Parent/Guardian Name(s):
Home Phone:
Place of Employment:
Parent/Guardian Email:
Is this your Child’s 1st time at Summer camp at Manitou-Lin?

Camper Personal Information: (Optional, but very helpful in working with your camper)
Child Lives with:
Both Parents Mother Father Other
Has your camper experienced any recent life changes that may affect his/her time at camp?
Check each word that describes your camper with children their own age:
Shy Friendly Quiet Outgoing Leader Follower
Does your camper make friends:
Easily Fairly Easily With Difficulty
Does your camper express feelings :
Easily Fairly Easily With Difficulty
Does your camper have any special needs?
Child is looking forward to camp with:
Enthusiasm Acceptance Caution Anxiety
Has your child been away from home before?
Yes No
If so, where?
How Long?
What serious fears does your camper have?
Is your camper:
Slow Dresser Slow Eater Afraid of water, darkness, etc?
Is your camper subject to:
Bed Wetting Sleepwalking Constipation Nightmares Fainting Tiring Easily Asthma Nervousness
Other: please explain:
Comments:
What do you consider your camper’s strengths and weaknesses:
What do you hope your camper gains from their camp experience?
What other information might help the counselor better understand your child?
Any specific activities to be encouraged or limited by physician’s advice:
Dietary Restrictions/Concerns:
Does not eat red meat Does not eat poultry Does not eat pork Does not eat eggs Does not eat dairy Picky eater
Other:
Allergic to or have strong dislikes for certain foods:
Camper’s ethnic/ racial background: (Optional):
White African American Hispanic or Latino Asian or Pacific Islander Native American Multi-racial
Other

EMERGENCY CONTACT INFORMATION including Parent/Guardian(s)
1st Contact Name: Phone 1
Relationship to Camper: Phone 2
2nd Contact Name: Phone 1
Relationship to Camper: Phone 2
3rd Contact Name: Phone 1
Relationship to Camper: Phone 2
4th Contact Name: Phone 1
Relationship to Camper: Phone 2

 

 

PARENT RELEASE AUTHORIZATION FORM
All campers being picked up from YMCA Camp Manitou-Lin or at a Day Camp bus stop, must be signed out with a camp staff member. Please list all people your camper may be released to INCLUDING parents and guardians. Positive photo ID is required.
NAME (including parent/guardian RELATIONSHIP
1.
2.
3.
4.
My child may NOT be released to:
Date:
Signature of Parent/Guardian:

 

YMCA Camp Manitou-Lin HEALTH HISTORY
General Health History- Please Check yes or no. Explain ‘yes’ answers below.
Has/Does your camper:
Ever had surgery Yes No
Had a recent infectious disease Yes No
Had asthma/wheezing Yes No
Had seizures Yes No
Wears glasses or contact lenses Yes No
Passed out during exercise Yes No
Have problems sleeping Yes No
Have any skin problems Yes No
Have recurrent/Chronic illnesses Yes No
Had a recent injury Yes No
Have diabetes Yes No
Had severe headaches Yes No
Had fainting or dizziness Yes No
Had Mononucleosis in the past year Yes No
Have problems bedwetting Yes No
Have problems with diarrhea/constipation Yes No
Please explain any “yes” answers below: Please use a separate page if needed.

 

This camper is up to date on all immunizations required for school

(Signature of Parent/Guardian)
If your campers has NOT been fully immunized. Please sign the following statement: I understand and accept the risks to my child from NOT being fully immunized.

(signature of custodial guardian/parent)
Date of last Tetanus Booster Shot: (date required)
Name of family physician:
Phone:
Date of last physical examination (must have been within the last 24 months):
Family medical/hospital insurance carrier:
Policy or Group #:
(For female) Has this person menstruated?
Yes No
If no, has she been told about it?
Yes No

 

MEDICATIONS BEING TAKEN

Please list ALL medications (including over-the-counter or non-prescription drugs) taken routinely. Bring enough medication to last the entire time at camp. Keep it in the original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration. Attach additional pages for more medications.
Camper takes NO medications. Camper takes routine medications. Camper takes routine medication during the school year.
This person takes the following medications: (Please attach additional pages for more medications)

Med #1: Dosage Specific times taken each day
Reason for taking:
Med #2: Dosage Specific times taken each day
Reason for taking:
Identify any medications taken during the school year that participant does/may not take during the summer:
ALLERGIES (List all known)

Medication Allergies



Food Allergies



Other Allergies


Describe reaction and management of the reaction.












I authorize the following to be administered as needed:

Tylenol Chloreseptic Benadryl Cough Drops Pepto Bismol Ibuprofen
Neosporin Calamine Lotion Comments:

GENERAL LIABILITY:

I understand that the YMCA of Greater Grand Rapids assumes no responsibility for injuries, which I or my child may sustain as a result of my or my child’s physical condition or resulting from my or my child’s participation in any activities, programs, exercise, or the use of any facility, equipment, or other activities organized or sponsored by the YMCA of Greater Grand Rapids & Affiliates. I expressly acknowledge that I assume risk for any and all injuries and illnesses that may result. In consideration of the privilege of joining, or using the YMCA, I hereby voluntarily release and discharge the YMCA of Greater Grand Rapids, its agents, servants, and employees from any and all claims for injury, death, loss or damage that I or my child may suffer. I understand the YMCA of Greater Grand Rapids is NOT responsible for personal property lost or stolen while members and/or program participants are using YMCA facilities or on YMCA premises.

PHOTO RELEASE:
We love taking pictures of our guest enjoying their time at Camp Manitou-Lin. We often use these photos in our marketing and promotional efforts. By signing this waiver, you agree to give the YMCA of Greater Grand Rapids permission to use any media of me or my child at camp for purposes of promoting or interpreting YMCA Programs. If you’d prefer your photo not be used, please let us know in writing prior to your camp experience.

Signature Date

EQUINE LIABILITY RELEASE:

Please read the following agreement and liability release for horseback riding and or horse related activity at YMCA Camp Manitou-Lin before signing:

WARNING: Under the Michigan equine activity liability act, an equine professional is not liable for an injury to or the death of a participant in an equine activity resulting from an inherent risk of the equine activity.

ACTIVITY RISK and NATURE OF CAMP HORSES
As a guest at YMCA Camp Manitou-Lin, I, the undersigned, recognize that YMCA Camp Manitou-Lin is located in a rustic setting with natural and artificial hazards (including surface and subsurface conditions). The undersigned also understands that it is the propensity of an equine to behave in ways that may result in injury, loss, or death. Equines can act unpredictably to sounds, sudden movements, unfamiliar objects, persons, or other animals. It is also understood by the undersigned that there could be a collision with another equine, animal, person, or an object while riding on YMCA Camp Manitou-Lin premises.

RIDER RESPONSIBILITY
The undersigned will be given basic riding instruction prior to riding, yet there is a potential for the participant to act or fail to act in a manner that could contribute to injury, loss, or death. I understand that by mounting a horse and by taking the reins that the rider is in primary control of the horse. The rider’s safety largely depends on his/her ability to carry out simple instructions and his/her ability to remain balanced aboard the moving equine

SIGNER STATEMENT OF AWARENESS
I/We, the undersigned, have read and do understand and agree to the foregoing agreement, warnings, waiver, and the assumption of risk. We assume the risk of injury from the above danger, and waive liability, if any, of YMCA Camp Manitou-Lin/YMCA of Greater Grand Rapids and its staff and volunteers.

Signature Date

EMERGENCY AUTHORIZATION
I hereby give permission to the medical personnel selected by the camp director to provide routine health care; to administer medications; to order X-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for myself or my child. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization, for the named person above.

Signature Date

For reporting purposes please consider answering the following. This information is confidential and is used for applying for grant opportunities.
Total number of people in the household:
Annual Household Income
Less than $5000 $5000-$9999 $10,000-$14,999 $15,000-$24,999 $25,000-$34,999
$35,000-$49,999 $50,000-$74,999 $75,000-$99,000 $100,000 or more