Camp wood ymca

This letter to your cabin counselor will help him/her get ready for your arrival at camp. The information you provide will help your counselor get to know you better. Your counselor will also use some of the information to help them plan afternoon activities for you and your cabin mates. My full name is The things I like to do most with my friends are ___________________________. What I like most about school is and what I like least about school is ____ The sports or activity that I enjoy the most are Most of my friends would probably describe me as someone who is ____. If you were to ask my best friend about me, they would say that I ____. The qualities I like most in people are The kind of counselor that I would like to have most is one that As my counselors, I also want you to know that ____. When I get to Camp Wood, the things I want to do most are _________. Some of the things I don't like to do are Circle one of the following: (I have) or (have not) been to camp before. The camp name and year that I attended was _______. Camp Wood Agreement "I agree to abide by the rules established by all campers and to use behavior appropriate to Camp Wood YMCA. I agree to try new activities and to become a part of my cabin group. I agree not to use bad language, drugs, tobacco, or alcohol in any form while in camp or on a cap trip. I also agree to respect fellow campers and the camp's natural environment." Parents, this letter is to help your child’s counselor understand what you hope your child gains from their Camp Wood YMCA experience. The kind of counselor I want for my child is one that ______________________________________________________ _____________________________________________________________________________________________________________________ I hope my child gain this from their Camp Wood experience ______________________________________________________ _____________________________________________________________________________________________________________________________ How would you describe your son our daughter? Please include anything that would help us understand him/her. Have there been any recent changes in their life (a move, death. separation, birth of sibling?) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ How does your child get along with children their own age? _________________________________________________________ ________________________________________________________________________________________________________________________________ Does your child have any problems that affect his/her behavior (ADD, ADHD, ODD, etc)? If so, what is the best way to manage these behaviors? What works and what doesn’t? ____________________________________________ _______________________________________________________________________________________________________________________________ With your child, what is the best method of discipline to use if necessary?_______________________________________ _______________________________________________________________________________________________________________________________ If your child expresses interest in extending their stay at Camp Wood YMCA may we contact you to explore this possibility? Please circle one If you have been a camper at Camp Wood YMCA before, please complete the information below. While at camp during the previous summer(s), the things which helped me grow the most were: I have decided to return to camp because: How did your camp experience help you during the school year? What was the best part about your last summer at camp? ________________________________________________________________________________________________________________________ If you could change anything about camp, what would it be? Camp Wood YMCA Health History Form
Please fill out completely and returned three weeks prior to your
child attending camp.
for Summer Residence Camp
Mail to: Camp Wood YMCA 1101 Camp Wood Rd. Elmdale, KS 66850 The information on this form is not part of the camper or staff acceptance process, but is gathered to assist us in identifying appropriate care. History form (first three pages) must be filled out by parents/guardians of minors or by adults themselves. Update is required annually. An approved licensed medical personnel must sign the last page at least every two years.
Custodial parent/guardian

Second parent/ guardian or emergency contact

If not available in an emergency, notify
Other than the participants’ parents, the following people have my permission to pick up my child from Camp Wood YMCA ttending

ALLERGIES List all known medication, food or other allergies including insect stings, hay fever, asthma, animal dander, etc. Describe reaction and management of the reaction.
Session A

Dietary Restrictions: Please list any dietary restrictions. (not eat red meat, pork, eggs, poultry, seafood, dairy products, wheat or milk allergies, etc.

Insurance information
Is the participant covered by family medical/hospital insurance? Yes Photocopy of front and back of health insurance card must be attached to this form!
This health history is correct and complete as far as I know. The person herein named has permission to engage in all camp activities except as noted.
I hereby give permission to the camp to provide, seek, and consent to routine health care, administration of prescribed medications, and emergency treatment for me/my child, as may be necessary, including, but not limited to x-rays, routine tests and treatment, and/or hospitalization. I also give permission for the camp to arrange related transportation. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. It is my intention that the camp be treated as acting in loco parentis if the person herein named is a minor. Further, it is my intention that the appropriate representative of the camp be treated as “personal representatives” for the purposes of disclosing protected health information pursuant to the privacy regulations promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996. I hereby agree (pursuant to 45 CFR § 164.510(b)) to the disclosure to camp representatives of the protected health information of the person herein described, as necessary: (i) to provide relevant information to the camp representative related to the person’s ability to participate in camp activities; and (ii) in case of minors, to provide relevant information to the camp representative to keep me informed of my In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to secure and administer treatment, including hospitalization, for the person named above. This completed form may be photocopied for trips out of camp. * If for religious reasons you cannot sign this, contact the camp for a legal waiver which must be signed for attendance.
MEDICATIONS BEING TAKEN Please list ALL medications (including over-the-counter or nonprescription 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.
This person takes NO medications on a routine basis. This person takes medications as follows: Attach additional pages for more medications Identify any medications taken during the school year that participant does / may not take during the summer:
Is the participant up to date on all immunizations? Yes No Date of last tetanus(DTP/TD) shot:_______________________
Staff only:TB Mantoux Test

Over the Counter Medication Use Please review the following over the counter medications and circle any options listed you DO NOT want your child to receive. Camp Wood
YMCA typically uses the generic form of the name brand medications listen below. Sunburn Solarcaine, Aloe Vera gel
Allergies Claritin, Benadryl
Diarrhea Kaopectate,
Red Irritated Eyes Clear Eyes Visine
Constipation Milk of Magnesia, Dulcolax
Poison Ivy Ivy Rest, Calamine Lotion, Caladryl Lotion, Hydrocortisone Cream
Sore Throat Chloraseptic Spray Lozenges
Headache / General Discomfort / Fever Tylenol (Acetaminophen), Advil (Ibuprofen)
Discomfort from water in ear Swim Ear
Upset Stomach Pepto Bismol, Mylanta or other antacid, Rolaids
Cough/Cold Cough Syrup Nasal Decongestant Cuts & Abrasions: Hydrogen peroxide, Neosporin
Insect Bites Benadryl
1. Recent injury, illness or infectious disease? 15. Ever had problems with joints (e.g., knees, ankles)? … 27. Ever had high blood pressure? ………. 2. Chronic or recurring illness/condition? …. 16. Have an orthodontic appliance being brought to camp? . 28. Ever had back problems? ……………. 3. Ever been hospitalized? …………………… 17. Have any skin problems (e.g., itching, rash, acne)? …… 29. Hayfever…………………………………. 4. Surgery? ……………………………………… 18. Have diabetes? …………………………………………. 30. Poison Ivy Allergy………………………. 5. Frequent headaches? ………………………. 19. Have asthma? ………………………………………………. 31. Insect sting allergy……………………… 6. Ever had a head injury? …………………… 20. Had mononucleosis …………………………………………. 32.Frequent sore throats…………………… 7. Ever been knocked unconscious? ………. 21. Had problems with diarrhea/constipation? ……………… 33. Heart Disease…………………………… 8. Wear eye wear? …………………. 22. sleepwalking? ………………………………………………. 34. Clotting disorder………………………… 9. Ever had frequent ear infections? ………… (a) have you begun menstruating? ……… 35. Fears/Phobias…………………………. 10. Ever pass out during or after exercise? …. 36.Behavior Problem………………………. 11. Ever been dizzy during or after exercise? …. 24. Ever had high blood pressure? …………………………… ADD/ADHD……………………………… 12. Ever had seizures? …………………………. 25. bed-wetting? ……………………………………….… 38. Speech problems………………………. 13. Ever had chest pain during or after exercise?. 26. Ever have an eating disorder? …………………………… 39. Hearing problems………………………. 14. Ever had emotional difficulties for which professional help was sought? …………………………………………………… 40. Vision problems………………………….
Please explain any “yes” answers, noting the number of the questions.


Use this space to provide any additional information about the participant’s behavior and physical, emotional, or mental health about which camp should be aware.

Please list and explain any restrictions to activity (e.g., what cannot be done, what adaptations or limitations are necessary)
Treatment

Doctor’s Physical Examination: I have examined the above participant on _________________ and in my opinion he/she is / is not able to participate in an active camp program.
I HEREBY CERTIFY THAT I AM QUALIFIED BY TRAINING AND EXPERNIENCE TO PROPERLY PERFORM THE EXAMINATION AND MAKE THE EVALUATION REFLECTED ON THIS FORM
Signature of physician
,MD, PA, or CNP
Name of physician (print / type) Date

Source: http://www.campwood.org/pdfs/required_forms.pdf