8.B. PRSR 03-13-2002 - Laserfiche WebLink

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[ _ _„„,.._ YMCA Emergency& Health Information • Please complete both sides and return to: Elk River Recreation Department • 1104 Lions Park Drive• Elk River, MN 55330 PLEASE USE ONE FORM PER CHILD AND PRINT NEATLY Child's Name(please print) ❑ Female ❑ Male Home phone( ) E-Mail Address City State Zip Birthdate / / Grade in Fall 2002 School in Fall 2002 Parent/Guardian Home phone( ) Work Phone( ) Cell phone/Pager( ) Parent/Guardian Home phone( ) Work Phone( ) Cell phone/Pager( ) Child Resides with ❑ Mother ❑ Father ❑ Both ❑ Other How did you hear about us? ❑School ❑ Word of mouth ❑ Brochure: _received in mail_received at school_picked up at YMCA Are you a YMCA member? ❑ Yes(Member# ) ❑ No I would like YMCA programming updates forwarded to me via e-mail ❑ Yes ❑ No EMERGENCY CONTACTS AND PICK UP AUTHORIZATION Has child has any of the following,and if so,please explain: The following people should be contacted in case of ❑ Operations or serious injuries emergency,only if parent or guardian cannot be reached AND (date/s) are authorized to pick up the child: ❑ Chronic or recurring illnesses 1.Name Relationship to child ❑ Allergies or Asthma IllkPhone:Day( ) Evening( ) ❑ Dietary restriction(s) .Name ❑ Special Needs Relationship to child Is the child taking any medications? ❑ Yes ❑ No Phone:Day(_) Evening(_) If yes,what kind and why? 3.Name Relationship to child Phone:Day(_) Evening( ) If medication needs to be administered during the program,a 4.Name Medication Permission Form must be completed. Call the YMCA Relationship to child for this form or pick it up at your site. Phone:Day(_) Evening(_) Status of child's vision,hearing,and speech Family Doctor Phone( ) Please comment on your child's swimming ability Family Dentist Phone( ) Do you carry medical/hospital insurance? ❑ Yes ❑ No Does your child have a communicable disease or condition Carrier which may prove to be a risk to others? ❑ Yes ❑ No Policy/Group# If yes,please comment: REQUIRED: Month,date and year of most recent immunizations: Other significant information about your child's behavior that DPT Polio would be helpful to know: Measles Mumps Rubella HIB Photographic Release I hereby release all pictures of my child taken by the YMCA for promotional purposes and programming materials including the YMCA website ❑ Yes ❑ No Initials Medical Records Release I agree to the release of any records necessary for treatment,referral billing or insurance purposes. The YMCA receives medical information on campers/participants that may need to be shared with medical providers ❑ Yes ❑ No Initials earent/Guardian's Authorization n the event that my child needs immediate medical attention for injuries received while participating in a YMCA program,I authorize the YMCA staff to give my child reasonable first aid,and to transport my child to a health care facility for emergency services as needed. My child has permission to be transported by the YMCA to and from field trips. I authorize YMCA staff to administer syrup of ipecac when instructed to do so by a poison control center.I hereby acknowledge that the YMCA will assume that either parent of the child may pick up the child at any time during the program unless there is pertinent court documentation on file at the ymca that indicates otherwise. Parent/Guardian Signature Date