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2000 Frost Valley Road, Claryville, NY 12725Ph: (845)985-2291 Fax: (845)985-0059 FrostValley.org DATE OF TRIP FROM________ TO_______
School ________________________________________
Lead Teacher ___________________________________________
Student Health Information
Student Last Name _____________________________ First Name ______________________________________________
Parent/Guardian’s Name _______________________________________________________________________________
Phone Number: (home) ________________________ (work) ______________________ (cell) ______________________
Home Address _________________________________________________________________________________________
Family Physician ____________________________________________________________ Phone _____________________
Insurance Company ________________________________________________________ ID# ________________________
In an emergency, if unable to reach parent, contact:
Name ______________________________________________________________________ Phone _____________________
Name ______________________________________________________________________ Phone _____________________
Health History: (please check all that apply and explain):
Comments: ____________________________________________________________________________________________
________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Any known allergies (Food or Drug): _____________________________________________________________________
Diet Restrictions ____________________________________________________________________________________________
Date of Last Tetanus Shot _______________________
-------------------------------------------------------------------Cut here when needed------------------------------------------------------------------ *Note: 3 signatures requried below*
Authorization to Consent to Treatment of Minor Temporarily Separated from His/Her Parents
I, the undersigned, parent or legal guardian of (child’s name) _______________________________________________ , a minor, am familiar with the program and the general nature of activities planned during their trip to Frost Valley YMCA, and to the best of my knowledge the above information is correct and my child is capable of participating in and has permission to engage in all activities. I do hereby authorize (School Name) _____________________________________________________________ (Lead Teacher) ________________________________________________________________________ diagnostic procedure or medical care which is deemed advizable by, and is to be rendered under the general or special supervision of any liscensed physician at the nearest hospital with facilities appropriate to my child’s injury/illness. This authoriza- tion shall remain effective until (day after the last day of the trip)_____________ unless sonner r Parent/Legal Guardian’s Signature _____________________________________________________ Date __________________________
Student waiver of liability
I hereby accept any and all responsibility for, and assume the risk of any and all injury or damage to my dependent children which might arise directly or indirectly as a result of, and or participation in the Frost Valley YMCA program. I hereby expressly release, discharge and hold harmless from any liability whatsoever the Frost Valley YMCA and all employees and volunteers in their capacities as representatives of the YMCA. Except for injuries caused intentionally, or by willful misconduct, I certify that I am familiar with the contents of this release, that I have read and understand the same, and that it is my intention by signing this release that the same is binding not only of me, but my heirs, administrators, executors, successors and assigns.
Parent/Legal Guardian’s Signature _____________________________________________________ Date __________________________
Student Model and Statement Release
Periodically, Frost Valley YMCA uses photos and statements made by participants in the Frost Valley YMCA programs for news- letters, fund raising efforts, brochures and articles about Frost Valley YMCA. All photos and statements are used with reasonable judgement for purposes directly relating to the operations of Frost Valley YMCA. This signed form gives Frost Valley YMCA permis- sion by the signer to utilize participant photos or statements for the purposes mentioned above.
Parent/Legal Guardian’s Signature _____________________________________________________ Date __________________________
2000 Frost Valley Road, Claryville, NY 12725Ph: (845)985-2291 Fax: (845)985-0059 FrostValley.org Written Doctor and Parent Permission Form
PLEASE NOTE: All medications, vitamins, supplements, or topical treatment require
written permission from a physician and parent
Camper Last Name_____________________________________________First Name______________________________________
D.O.B ___________________________________ Weight______________Allergies________________________________________
Physician’s name: ______________________________________________Phone #________________________________________
The following over the counter medications are available in the health center. It is not necessary to send these medications with the
students. These medications can be administered by a Registered Nurse per label instructions by age and weight only if Parent and
Physician signature is documented below. Note: All medications must be sent in original packaging.
Drug Name
Schedule and Indications
To be adminis-
tered if needed
Q 4h as needed for pain or fever>___-F Q 6h as needed for pain or fever>___-F (chewable tabs, elixir, suspension or tabs) Q 4h nasal congestion *not more than 4 doses in 24 Q 6 h as needed for allergic reaction, hives, insect 30 minutes prior to sun exposure as needed for out- Physician
Please document below the patient’s current medication regime for both scheduled and “as needed” medications routinely received by the above noted minor.
Prescribed Medication
6FKHGXOH%H6SHFLÀF
Comments
Self-carry medication release for Sun block, Rescue inhalers, epi–pens and insulin pumps
We request that the above named camper/student be permitted to carry one or all of the following:
(Please check all that apply and indicate MD order above)
‡ Sun block
Comments:__________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
The above noted ‘self-carry” items/medications are permitted for the indicated minor at all times. He/She has been instructed by the physician and
parents and acknowledges the proper understanding of the purpose, frequency and appropriate method of use of these items.
As I consider him/ her responsible, I will not hold Frost Valley YMCA personnel responsible for any errors which may arise in my child’s self
administration of these items/medications.
MUST HAVE THE FOLLOWING SIGNATURES OR NO OVER THE COUNTER, PRESCRIPTION OR SELF-CARRY MEDICATIONS CAN
BE ADMINISTERED AT CAMP
Physician /Health Care providers Signature: ____________________________________________________________________________
Phone #_______________________________Address: _____________________________________________________________________
Parent Signature: ___________________________________________________________________Date:___________________________

Source: http://www.whbschools.org/cms/lib2/NY01001014/Centricity/Domain/250/2012%20FV%20Student%20Medical%20Forms%20and%20Waivers.pdf