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<br />Child's Nome
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<br />Chain of Lakes YMCA Summer Programs Emergency & Health Information Fom
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<br />Please fill oul co~lelely and rm 10: CIoaIa.f Lakes YM<A . 1690 VUIage Drive . Uno Lakes, MN 55014 .
<br />I'l.fA5E USE ONE FORM PfII WIlD AND I'fINT NEAnY.
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<br />lhi~'sFirYNume Midd~lnitiol loslNome Birthdot, Gende<OF OM
<br />Grode . Foil 1008 Ag, _ 5<1..01 . Full 1008
<br />C~~ resides wilh 0 Moll1er 0 FuIl1er 0 Bolh o Other
<br />AIe you 0 YMCA member? 0 Yes (Member I ) ONo
<br />II Porent/Guonloo', FiIsI Nume Midd~ lnitiol lost Nume
<br />Addre~ Gty 510te Zip
<br />Poreot/Guorrlion'sBir1hdot, Gender 0 F 0 M Home Phone ( ) EiIIOil
<br />Per"'f/Guorrlion's WIlIk Phone ( C,II Phone ( )
<br />11 Porenf/GrJerdion's FilSt Nome Middiolnffiol Lost Nome
<br />Address Oly SIoIe Zip
<br />Perenf/Guordiun's Bir1hdot, Gender 0 F 0 M Hom, Phone ( ) E-moil
<br />Porent/Guonf.n's WIlIk Phon, ( Coil Phone (
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<br />PIIooe: 651-195-9622 . F.x: 651-184-1135
<br />Dote(~
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<br />EMERGEIICY COIITACTS DO PlCI.UP AUTHORlZATIOII
<br />TIoe IoIowlllg peepIe should be loata<ted I. ,"so 01 _......" 0IIIy N pare.. or
<br />S....... c..... be reached AND are au.horbed ,. pick ap ... c1ild:
<br />1. Nome
<br />RoIotio'"~ploc~~
<br />Phone: Iloy L-J Evening L-J
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<br />1. Nome
<br />R,lolionshiplochi~
<br />Phone: Ooy L-J
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<br />Evemng(~
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<br />Fom~y DocIII
<br />Phone (
<br />Fo",1yDeofi~
<br />Phone ( )
<br />Do you corry Iom~ medk,l/hospilol insuronce? 0 Yes 0 No
<br />(orrie,
<br />Policy/Group'
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<br />MOIITH. DATE AID YUR OF MOST RECEIIT IMMUIlIZATIOIIS:
<br />DPT PoIiu
<br />Mer~,s Mumps
<br />ROOeIIo HIB
<br />T'I000<
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<br />IS THE CHILD TAKIIIG AllY MEDIClnOIlS? 0 Yes 0 No
<br />H yes, whot ~nd und why:
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<br />N.......... _10 be admii....ed dorrirog!he pr"ll..... . MetIcefion Pemission
<br />F.... nISI be completed. CaI !he YMCA far ....Iann, or pick ft .... ,.. site.
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<br />HAS CHILD HAD AllY OF THE FOUOWlII&. AIID IF SO. po sa... EIPUIII.
<br />o Speriol needs
<br />OAllergiesorAsthmo
<br />ODieIoryreslTicfioo/s
<br />OOrOOK or recurring W""'"
<br />o Operntioos 01 serio.. i~uries (include dOlO/s)
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<br />S_ofcMd'svisioo,heoring,ondspeech
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<br />Does your chi~ hov, 0 coromunicob!e diseose 01 condffioo which moy prove 10 be u risk 10 otbers?
<br />DYes ONo
<br />If yes, ~eose com",,",
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<br />SIGIIIFICAIIT IIIFOII_anOIl AlOUT YOUR CHILD'S BEHAVIOR THAT
<br />WOULD IE HELPFUL TO IIIOW:
<br />
<br />Wli.. oIlW111ty
<br />IlII<ielshnIllmllE \'wig Men',OIisIion_oI_Soiot Pwl """'" oo"""",biiyfor~oiesll~.....wl1ich mym""cN~ "",mil or a..Jtolmy physi:.rond1ion N re<lJimII horn I"f1i<ijmion. uny
<br />"''''''' progIlI1I OCIMlies NexpeIieoces.1 "flII!IlIt ocInowIedgeoo beldfolmy nioor dill and ",,,11m I a.uroo!he rilkforulf)'md 01 i~oiesund I..... wIi<h "'" ..Jtlrom my..oord1ild's pIIIi<ijoIion in """_
<br />If my child requires use and administration of on epi-pen, it is my responsibility 10 ensure that the epi-pen is on my child or within their pelSOllol belongings everyday 01 !he progrom. If Choin of lokes YMCA or Camp
<br />stoff ;s required to administer and use the epi-pen thotl ogree to lorevel release and dischorge the YMCA and ils' direuors, officers, and employees from ony and ollliobility arising oul 01 or resulting from use 01
<br />ndministrU1ian oIlh, epfpen. I hereby reIeuse md dOchoye m, YMCA 10;" .0<1015, oIIm. onpOyeor md........ horn eny md aD ooms for oemls, k1jJries, deo1h,... N ~.tJi<h I N my moor di~ "'" ""'" or 0 re<lJhs
<br />0I;mi<ile1ilg."""_
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<br />1. In m, _riKII my di~ needs inrnedil1e mol,. one.... IN injuries ",eiwd while I"ffi<iI<ning in u YMCA PfOIIIOm,l ullllorize!he YMCAstoIfro g.. my dild 0lllllIIdJIe 6rs1 001, and 10 mmnge _ 01 my chld 10 u Ioohh coe
<br />'dly (II 'mogen<y sel'lices os needed.
<br />1 I ogree 10 m, reioore 01 OIly reclllis n"""'Y lor _, ref..., ~Iing N i""""" jUpOSOS.lIE YMCA ",elves mol.. i1fCllJl1Olioo 00 cempe./jllrlidpools 11m my nmd 10 be...red wim me&cO pnMdeo.
<br />3. Myd;ldlmmypenniSlioolobe1nl1lpOCledby1heYMCAloondfromliell.
<br />4. I hereby edc""'"'lie IImm, YMCA wI IISllJm'mU1 ei1her porefI1 01 !he chid ""'lick~!hemld U1unyfimeclurilll!he PfOI/OIIIun..1hereispellinen,coort_ onli1eU1lhe YMCA lIm_a_.
<br />5. I hereby reIeuse uI jirnJesol my mld 1okoo byll1e YMCA lor promoIiaoo'l'llJ'lS'l mdprogrnmmilll","",,'io:lOOmg!he YMCAwebsiIe.
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<br />Per"'t/GuordionS~"""""
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