TYM Camp - Health Form • Today's Youth Matter

Child's Information

Welcome! We are delighted to have your child(ren) attending TYM Camp July 6-10. The following Health Form provides us with key information about your child so we can provide a high level of care during camp. If you have multiple children, you will complete this form for each one. If you have any questions or run into any challenges, please contact our team at: camp@tymkids.org

First Name *

Gender *

School *

Last Name *

Date of Birth *

School Grade *

Tip: Please enter grade child will be entering in the Fall

Parent/Guardian #1 Information

P/G Name *

P/G Mobile # *

P/G EMail *

P/G Phone *

Parent/Guardian #2 Information (Optional)

P/G 2 Name

P/G 2 Mobile #

P/G 2 Email

P/G 2 Phone

Emergency Contact for Child

Emerg Name *

Emerg Email *

Relationship *

Emerg Phone *

Medical Information

Is Child covered by Health Insurance *

Yes

Insurance Company Name

Please list any allergies your camper has. For each allergy, please include the typical reaction and whether there is any risk for Anaphlaxis.

Does your child have any allergies (food, medicine, environment, insects, other)? *

Yes

Activity Restriction Information

Camp activities that you will not want your camper to participate in?

Tip: Select activities not allowed

List Activities not allowed *

Diet and Nutrition

List of additional dietary restrictions

Mental, Emotional and Social Health

Mental Questions (check if ever been treated for the following)

Attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (ADHD)

Emotional or behavioral difficulties or an eating disorder?

During the past 12 months, seen a professional to address mental/emotional health concerns

Had a significant life event that continues to affect the camper's life? (history of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others)

Please explain any mental/emotional checked items here.

Other Information

Please provide any other information that will assist us in caring for your child while at camp

Authorization and Consent

I hereby attest that the Health History noted in this application is correct and accurately reflects the health status of the child to whom it pertains. I permit the licensed medical professional selected by the Camp Director to order x-rays, and routine tests and offer treatment related to the health of the child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the licensed medical professional to hospitalize, secure proper treatment for, and/or order injections, anesthesia, or surgery for the child. I understand the information on this form will be shared on a "need to know" basis with camp staff. In addition, the Camp has permission to obtain a copy of the described child's health records from providers who treat them and these providers may talk with the program's staff about the described child's health status. I give my permission to photocopy this form.

I authorize and consent to the above medical statement *

Yes

Media & Photo Release: I hereby give permission for my child to be interviewed, photographed, videotaped, and/or recorded while participating in the programs of TYM Camp and for her/his image/comments to be used for the purposes of camp reporting, promotion, advertisement, or illustration. Use of any such photographs, videotapes, or interviews may include but are not limited to use on internet sites promoting TYM Camp.

I give permission for the Media & Photo Release *

Yes

I hereby give my consent and permission for my child to attend TYM Camp and to participate in all camp activities unless otherwise noted in this application. I permit TYM to use my child's image/comments for the purposes of camp reporting, promotion, advertisement, or illustrations. In the event of an emergency, I hereby permit the physician selected by the Camp Director to hospitalize, secure proper treatment, and/or order injections, anesthesia, or surgery for my child.

I accept the terms of the above camp attendance *

Yes