This is a two-sided document. Please fully complete both sides.
Last Name:
Middle Initial:
First Name:
Birth Date (MMDDYY):
City/Town State Zip
Identifying Marks: ________________________________________________ Grade entering
Male_____ Female_____ Not Specified_____
in fall 2021:
Parent or Guardian Information
Parent or Guardian Parent or Guardian
Address Address
(Only if different from address above) (Only if different from address above)
Phone Work Phone Work
Cell Phone Cell Phone
Email Email
Please list at least one emergency contact that, if necessary, could provide transportation home.
Emergency Contact Emergency Contact
Cell Phone _______________________ Work _______________________ Cell Phone _______________________ Work
Insect Bite/Bee Sting Severity: Mild Moderate Severe (circle one)
Yes (circle one) No Reaction ________________________________
Yes (circle one) No Reaction ________________________________
Severity: Mild Moderate Severe (circle one)
Food Yes (circle one) No Reaction ________________________________ Severity: Mild Moderate Severe (circle one)
Seasonal Yes (circle one) No Reaction ________________________________ Severity: Mild Moderate Severe (circle one)
Medications Yes (circle one) No Reaction ________________________________ Severity: Mild Moderate Severe (circle one)
Other Yes (circle one) No Reaction ________________________________ Severity: Mild Moderate Severe (circle one)
Please explain/specify any of the above that were answered “Yes” (i.e. type of food allergy, medication associated, etc.)_________________
If medications will be administered at camp for above allergies a Medication Information Form” must be completed
Physician Information
Name of family physician: ____________ Phone:
Insurance Information
Insurance Carrier: Policy Holder Name: Policy/ Group #:
Immunization History: Massachusetts requires a Certificate of Immunization for
all campers and staff. You may use the form provided or a copy from your doctor’s office. Check if attached
Physical Form: Massachusetts requires a report of a Physical examination within
the past 18 months. Check if attached
YMCA of Greater Boston
2021 Health History,
Contact, and Release Form
This is a two-sided document. Please fully complete both sides.
Accuracy of Information: This health history is correct so far as I know and the person herein described has permission to engage in all camp
activities except as noted.
Authorization for Treatment: In case of an emergency, I authorize the YMCA to administer first aid and to transport my child or (staff member)
to the nearest hospital emergency room and to order X-rays; routine tests and treatment; and to release any records necessary for insurance
purposes. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director, or his/her
designee, to secure and administer treatment, including hospitalization, for the person named above. This form can be photocopied for camp
Authorization for Medications/Topical Ointments: I authorize the YMCA Health Staff and its designees to administer the following medica tions
(on an “as needed” basis unless contraindicated): Acetaminophen (Tylenol), Ibuprofin (Motrin/Advil), Antacid (Tums), Diphenhydramine HCI
(Benadryl), sunscreen and Anti-Itch Creams.
Acknowledgment of Risk and Waiver: I understand and acknowledge my camper (or staff member) may participate in a variety of activities
including; swimming, boating, outdoor games, sports, rope course, off-site activities, field trips, and other rigorous physical activities. I hereby
release and discharge, and agree to indemnify and hold harmless the YMCA of Greater Boston and Hale Reservation Inc., and their officers,
directors, members, agents, employees, volunteers, and any other persons or entities on their behalf, against all claims, demands, and causes
of actions whatsoever, either in law or equity, relating to or arising from any participation, medical treatment, recommendat ion, transportation
or administration, or any lack thereof.
Signature _ _____________________________________________ Date __________________________
Photo Release: I authorize the YMCA of Greater Boston and American Camp Association to have my child’s (or staff members) photo to appear
in camp brochures, videos, on websites or other promotional literature.
Signature _ _____________________________________________ Date __________________________
*Signature of Parent/Guardian of Camper, Staff Member, or Parent/Guardian of Staff Member under 18 years of Age
Relevant Past Medical History, General Information, and Restrictions
Does your child (or staff member) have Asthma? Yes (circle one) No
*Will your child (or staff member) be bringing an inhaler to camp? Yes (circle one) No
Are there any physical, mental, or psychological conditions requiring medication, treatment, or restrictions while at camp?
*Does your child or (staff member) take any prescription or over-the-counter medication at home? Yes (circle one) No
Please list any past medical treatment or recent injuries:
Describe any specific activities from which your child (or staff member) should be exempted:
Any dietary modifications or restrictions? Yes (circle one) No Please explain:
Does your child have an IEP or 504 plan? Yes (circle one) No Does your child qualify for free or reduced lunch? Yes (circle one) No
Please circle the ethnic group the child most identifies with (circle one): Caucasian/White African American/Black Hispanic/Latino
Native Hawaiian or other Pacific Islander American Indian or Alaska Native Other
Does your child attend a YMCA Afterschool or Early Education program? Yes (circle one) No If yes, where? ___________________________
Are there any accommodations or services that we can provide to make the summer as successful as possible? __________________ _________
Does your child participate in ELL services? Yes (circle one) No Primary language spoken at home:
Please share any information that would help Summer Staff best serve your child:
*If Yes” a Medication Information Form must be completed
Camper or Staff Name: Birth Date:
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