dchealth

DAY CAMP SESSION # ______________

Complete and return to : Camp Foster YMCA, PO Box 296, Spirit Lake, IA 51360

CONFIDENTIALITY AND SECURITY OF INFORMATION – PROTECTED HEALTH INFORMATION

We restrict access to non-public personal information to those employees who need to know that information to provide services to you and your child. Health forms are secured in either the main office or the Health Director’s office until the end of summer camp season, and then they are stored in the camp archives.

CAMPER HEALTH HISTORY & INSURANCE INFORMATION

Parents fill out Parts A,B,C,D,E *****************************************************************************************************************************************

PART A CAMPER INFORMATION

Camper’s Name ___________________________________________________________________ D.O.B. ___________________________

Address ___________________________________________________________________________________________________________

(City) (State) (Zip)

Home Phone _______________________________________ Emergency Daytime Phone __________________________________________

**IF PARENT CANNOT BE REACHED, OTHER PERSON(S) TO CONTACT WHILE CAMPER IS AT CAMP

1. Name ________________________________________________________________Day Phone _________________________________

Address ______________________________________________________________Evening Phone ______________________________

2. Name ________________________________________________________________Day Phone _________________________________

Address ______________________________________________________________Evening Phone ______________________________

My child has permission to leave camp with any of the persons Under any circumstances, my child is NOT allowed to leave camp

listed below: with any of the persons listed below:

_________________________________________________ _________________________________________________________

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PART B HEALTH HISTORY (check all that apply, and give approximate dates, if possible)

ALLERGIES DISEASES OR HEALTH CONCERNS

_____ Hayfever _____ Chicken Pox _____ Ear Infection _____ Migraines

_____ Poison Ivy, etc _____ Measles _____ Rheumatic Fever _____ Nosebleeds

_____ Insect Stings _____ Convulsions _____ German Measles _____ Braces

_____ Penicillin _____ Mumps _____ Diabetes _____ Heart Murmer

_____ Peanuts, Nuts _____ Asthma _____ Behavior _____ Contact Lenses

_____ **Other food or drugs _____ Eczema _____ Hives

**Specify __________________________________________________________________________________________________________

Other Health concerns or details of any above ______________________________________________________________________________

__________________________________________________________________________________________________________________

Operations/Serious Injuries (Date & Explanation) ___________________________________________________________________________

__________________________________________________________________________________________________________________

Chronic/Returning Illness _____________________________________________________________________________________________

Medications the camper will be taking during his/her session:

MEDICATION NAME DOSAGE REASON FOR MEDICATION

__________________________________________________________________________________________________________________

**PLEASE SEND MEDICATION TO CAMP IN ORIGINAL CONTAINER WITH PRESCRIPTION LABEL ATTACHED

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PART C IMMUNIZATION HISTORY (Please list dates as accurate as possible)

_____ DPT Series _____ BOOSTER _____ TETANUS BOOSTER

_____ POLIO OPV (Sabin) _____ BOOSTER _____ TUBERCULIN TEST

_____ MMR _____ OTHER (please list) _______________________________________________________________

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PART D PARENT’S AUTHORIZATION

I hereby give permission to the medical personnel selected by the camp director to provide routine health care; to administer medications; to order X-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the physicians selected by the camp director to secure and administer treatment, including hospitalization, for the person named above. Camp Foster YMCA will make every attempt to notify you before making a doctor’s appointment or an emergency room visit for your child while they are in our care. All minor medical needs will be cared for by the on-site Health Director without notification to parents.

__________________________________________________________________________________________________________________

Signature - Parent/Guardian Date

PART E INSURANCE/HOSPITAL REGISTRATION INFORMATION

**A COPY OF BOTH SIDES OF YOUR INSURANCE CARD NEEDS TO BE ATTACHED TO THIS FORM!

Camper Name ________________________________________________________ Gender ( M / F ) Birthdate _____________________

Address ___________________________________________________________________________________________________________

(City) (State) (Zip)

Father’s Name _____________________________________________________________Soc. Sec # ________________________________

Father’s Address ____________________________________________________________Home Phone _____________________________

Father’s Employer ___________________________________________________________Work Phone _____________________________

Mother’s Name ____________________________________________________________Soc. Sec # _________________________________

Mother’s Address ____________________________________________________________Home Phone _____________________________

Mother’s Employer __________________________________________________________Work Phone ______________________________

Family Doctor __________________________________________________ Phone # _________________________________

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INSURANCE INFORMATION

DO YOU HAVE _____ TITLE XIX _____ MEDICAID _____ NO INSURANCE COVERAGE

PLEASE LIST YOUR CARD NUMBER _________________________________________________________________________________

**PLEASE ATTACH A COPY OF YOUR INSURANCE CARD OR TITLE XIX CARD

If you have other insurance, please write name and address of insurance company ___________________________________________________

__________________________________________________________________________________________________________________

Is this coverage through: _____ Group/Father Employer _____ Group/Mother Employer

_____ Individual Policy _____ Other __________________________________

Policy Number _______________________________________ Group Number _________________________________________________

If you have secondary coverage, please provide this information:

INSURANCE COMPANY ______________________________________________ ADDRESS ___________________________________

_________________________________________________________________________________________________________________

POLICY OWNER _______________________________________________ POLICY NUMBER __________________________________

GROUP NUMBER ______________________________________________

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RELEASE OF INFORMATION/ASSIGNMENT OF BENEFITS

I authorize Spirit Lake Medical Center or Lakes Family Practice and associated physicians to release to the Medicare carriers or the insurance carrier listed above, any information needed for this or a related claim. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits either to myself or to the party who accepts the assignment on all future claims. I understand that I am financially responsible for all charges incurred.

__________________________________________________________________________________________________________________

Parent/Primary Insured Signature Date