Fillable - 2021 Overnight Camp Parent Packet

Fill Online, Printable, Fillable, Blank - 2021 Overnight Camp Parent Packet Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

- 2021 Overnight Camp Parent Packet

On average this form takes 57 minutes to complete

The - 2021 Overnight Camp Parent Packet form is 5 pages long and contains:

  • 0 signatures
  • 91 check-boxes
  • 184 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Participant’s Name:___________________________________________________________________________________________ Nickname:________________________________
Gender: _____________ Date of Birth: __________/________/_________ Grade (upcoming school year): ____________ Age as of May 1: ________
Parent/Guardian Name________________________________________________________ Cell Phone (______)_______-_________ Alternate Phone (______)_______-________
Parent/Guardian Name________________________________________________________ Cell Phone (______)_______-_________ Alternate Phone (______)_______-________
Home Address________________________________________________________________________ City___________________________________ State_____________ Zip_______________
Emergency Contact 1______________________________________ Relationship___________________ Cell # (______)_______-__________ Alternate # (______)_______-______
Emergency Contact 2______________________________________ Relationship___________________ Cell # (______)_______-__________ Alternate # (______)_______-______
**Parent/guardian will be contacted first in an emergency. If parent/guardian is unreachable, emergency contacts will be called.
MEDICAL INFORMATION
Name of family physician: _______________________________________________________________________________________________________ Phone (______)_______-_________
Name of family dentist/orthodontist: _________________________________________________________________________________________ Phone (______)_______-_________
Please attach health insurance information OR complete questions below. (Required at clinic or hospital for any medical treatment)
Self-pay/No Insurance at this time (Please indicate name and address of person responsible for payment)
Name: ___________________________________________________________________________ Address: ____________________________________________________________________________
Private Insurance
Insurance Company __________________________________ Policy # ______________________________________ Policy Holder's Birth-date _________/________/________
Name of Insured __________________________________________________________________ Relationship to participant ________________________________________________
PRESCRIPTION MEDICATIONS
The participant takes medication: Yes No
If yes, please note the following instructions:
Deliver any medications to Health Staff at check-in and fill out a medication instruction card detailing dosage and frequency.
-send in the original prescription bottle and only enough for the length of camp. Do not refrain from sending meds if participants take them at home.
-Our on-site health center staff collects and dispenses all prescription medications. No medication are allowed with participants in living units.
Medication:________________________________________________________________________Reason:___________________________________________________________________________________
Medication:________________________________________________________________________Reason: __________________________________________________________________________________
Medication:________________________________________________________________________Reason:___________________________________________________________________________________
Does your child carry an epi-pen Yes No Why?_____________________________________________________
Has camper begun menstruation? Yes No If not, have they been told about it?
Yes
No
Do they have a normal menstrual cycle? Yes No
Yes
Do they have permission and know how to use a tampon?
No
NON-PRESCRIPTION MEDICATIONS
Camp Staff will monitor the day-to-day needs of campers and may administer nonprescription medications, per package instructions in the
case of illness or injury. Utilizing medical history and discretion, camp staff may also administer Band-Aids and feminine products. I
authorize the following non-prescription medications to be administered to participants by the camp health care provider as needed:
Acetaminophen(Tylenol)
Yes
No
Benadryl
Yes
No
Ibuprofen
Yes
No
Antacid
Yes
No
Cough Syrup
Yes
No
Sudafed
Yes
No
YMCA CAMP WAPSIE
HEALTH HISTORY FORM / PARENT PERMISSION FORM
DUE MAY 1
Any changes to this form should be provided in writing upon
participant’s arrival at camp. Please provide complete information so
that the camp is aware of participant’s needs.
PLEASE INDICATE PROGRAM
Day Camp
LIT
CIT
Staff
Week/Session(s)_________________________________________
Please add all session your child will attend
YMCA Camp Wapsie / 2174 Wapsie Y Road Coggon, IA 52218 / F: 866.390.8490 / E: wapsieforms@crmetroymca.org
MEDICAL INFORMATION PAGE 2 Participant’s Name:___________________________________________________________________
PLEASE NOTE: If your participant has special health needs (including but not limited to: diabetes, cardiac illness, severe asthma, seizures, serious
behavioral issues, or severe allergies), you must contact the camp director for advance clearance. On a case-by-case basis, we consult with parent/
guardian and our camp health care provider to determine if accommodation and appropriate care is available.
PLEASE CHECK ALL BOXES
(a response is needed for each)
Asthma/Bronchitis
Yes
No
Frequent ear infections
Yes
No
HIV or AIDS
Yes
No
Migraines
Yes
No
Sleep walking
Yes
No
ADD/ADHD
Yes
No
Bedwetting
Yes
No
Cardiac Defect/Disease
Yes
No
Bleeding/Clotting Problems
Yes
No
Diabetes
Yes
No
Epilepsy or Seizures
Yes
No
Crohn's Disease
Yes
No
Fainting
Yes
No
Hepatitis
Yes
No
Conditions Not Listed
Yes*
No
*Please describe_______________________________________________________________________________________________________________________________________________________________________
1. Describe any other significant PAST medical treatment or history__________________________________________________________________________________
_____________________________________________________________________________________________ ____________________________________________________________________________
2. Describe any CURRENT physical, developmental, or psychological conditions requiring medication, treatment, special restrictions,
or considerations while at camp _________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________ ____________________________________________________
3.
Is the participant presently under the care of a physician for any conditions? Yes No
Name and phone number of treating physician ________________________________________________________________________________________________________________
Explain______________________________________________________________________________________________________________________________________________________________________
4.
Describe any camp activities from which the participant should be exempt for health or developmental reasons:__________________________
______________________________________________________________________________________________________________________________________________________________________
Food Allergy:
Dairy Soy Eggs Peanuts Tree Nuts Fish Shellfish Wheat
Other:____________________________
____________________________________________________________________________________________________________________________________________________________________________________________
5.
Diet Accommodations: Please complete if your child has a food allergy or special diet and provide more information below
Special Diet: Vegetarian Vegan Gluten (Celiac) Gluten Sensitivity
Lactose
ALLERGIES: LIST ALL KNOWN (Medications, food, environmental, etc.)
Allergy
_________________________________
_________________________________
_________________________________
Check all that apply
airborne ingested
airborne
ingested
airborne ingested
contact
contact
contact
Describe the reaction, severity, and a preferred response:
__________________________________________________________________________________________
__________________________________________________________________________________________
____________________________________________________________________________________________________
Please explain any other special diet needs or restrictions: ___________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________
IMMUNIZATION HISTORY
COVID – 19 Vaccination Dates: 1
st
__________________ 2
nd
________________________ Most Recent Booster____________________________
Please indicate date of last Tetanus Shot: Month____________________ Year ____________________________
As Guardian of the above-mentioned child, I attest my child has all up-to-date school-required immunizations. Yes No
This health history is accurate so far as I know and the above-stated person has my permission to visit and participate in all activities, except as noted above, at
YMCA Camp Wapsie. I hereby give permission for the camp staff to provide routine health care, administer prescribed and nonprescription medication, arrange
necessary transportation, seek emergency medical treatment, including X-rays, routine tests, injections and/or anesthesia and/or surgery, for camper named above. I
understand all precautions will be taken for camper care and supervision. I entrust care of my child to camp staff during their visit. Beyond this I will not hold camp
staff, Camp Wapsie or the YMCA responsible or liable.
By typing my name here I agree to the above information: __________________________________________________________________________________________________________
Updated 2/2022
* If there is something of special importance or major concern, please speak directly to your
child’s counselor at check-in
Letter to MY CHILD’S Counselor at YMCA Camp Wapsie
Name of camper: ____________________ Program(s): ______________ Week(s): _______
Dear Counselor,
This is my camper’s ________ year at overnight camp and _______ year at Camp Wapsie.
I want my camper to attend Camp Wapsie because
________________________________
______________________________________________________________________
______________________________________________________________________
While at camp, I hope my camper
_____________________________________________
______________________________________________________________________
______________________________________________________________________
My camper is…
… most happy when ____________________________________________________________
… most unhappy when __________________________________________________________
… enthusiastic about ____________________________________________________________
… not fond of __________________________________________________________________
… apt to be afraid of ____________________________________________________________
Describe the camper’s activity level: Very Active Active Moderately Active Inactive
Comments: ___________________________________________________________________
They are ________________________________ at taking care of personal belongings.
What behaviors do you most often have to speak with your camper about?
_______________
______________________________________________________________________
______________________________________________________________________
What methods of correcting these behaviors have you found effective?
__________________
______________________________________________________________________
______________________________________________________________________
Has your camper had problems with peers? If yes, please explain:
_____________________
______________________________________________________________________
My camper lives with (please name): Parent(s)/Guardians(s) ____________________________
Brother(s) ___________________ Sister(s) ____________________ Others _______________
My camper has the following responsibilities at home: _________________________________
Does your camper have a learning, emotional, or behavioral condition? If yes, please explain:
_____________________________________________________________________________
Anything else you would like us to know? ___________________________________________
_______________________________ _______________________ _________________________
Parent/Guardian
Primary phone number Secondary phone number
Letter to MY COUNSELOR at YMCA Camp Wapsie
My name is _____________________. My friends call me _______________________.
I am ______________ years old. After next summer I will be entering_______ grade.
My birthday is _________________________. I have _____________ brother(s),
age(s) _________________. I have ______________ sister(s), age(s) ____________.
The things I like to do for fun are ___________________________________________
______________________________________________________________________
______________________________________________________________________
I am good at ___________________________________________________________
______________________________________________________________________
______________________________________________________________________
I am coming to Camp Wapsie because _______________________________________
______________________________________________________________________
______________________________________________________________________
I hope to be able to do the following things at Camp Wapsie this summer ____________
______________________________________________________________________
______________________________________________________________________
When I am at Camp Wapsie I don’t want to ___________________________________
______________________________________________________________________
______________________________________________________________________
I get along with friends who _______________________________________________
______________________________________________________________________
______________________________________________________________________
Last summer I __________________________________________________________
______________________________________________________________________
______________________________________________________________________
I would also like you to know ______________________________________________
______________________________________________________________________
______________________________________________________________________
See you soon!
_______________________________
YMCA CA
MP WAPSIE
OVERNIGHT
CAM
P
RELEASE FORM
Camp Wapsie desires to provide a fun and safe experience for your child. Camp Wapsie uses a signature release
process. We will release your child only to individuals who you approve in writing.
On Saturday parents will pickup campers between at 9:00 – 10:00 AM. Specific times will be emailed to parents
prior to session. Please bring I.D. for checkout. Camp closes at 11:00 AM. The counselor will handle all sign-outs
in the cabin.
Please fill out and return entire form to YMCA Camp Wapsie
Child’s name
Sessions Attending
Program: Week# Pr
ogram: Week#
Parents/Guardians (ple
ase print)
Parent/Guardian Signat
ure Date
Phone numbers (Hm) (Cell)
(Cell)
The following people, other than parent/guardian are authorized to pick up my child from camp. Your child will not
be released to any person other than listed below.
Name Phone
Name Phone
Name Phone
For Staff Use
:
Child released to ID Shown (staff initial) Date
(To be signed when child is picked up from camp)
THE Y MISSION
: To put Christian principles into practice through programs that build healthy spirit, mind and body for all.
(Authorized person will print their name when picking up child)
________________________________________________________________________________________________________________________________________________________________________________________________
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

- 2021 Overnight Camp Parent Packet

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 26 April 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document