Camp Registration/Health Form


Dutchess County Gymnastics Center

Registration Information

Parent/Guardian Full Name:     Relationship:   

Parent/Guardian Full Name:     Relationship:   

Street Address:  

City:       State:       Zip: 

Phone Numbers:

Home:       Cell:       Work:   

Please provide additional emergency contacts in the event that the Parents/Guardians cannot be immediately contacted.

Emergency Contact #1:               

Emergency Contact #2:               

Student Information

Student Full Name:

Date of Birth:       Gender:         Grade:  

Health Care Information

Health insurance coverage is required for attendance of all activities at Dutchess County Gymnastics Center.

Insurance Company:        Phone:   

Subscriber:       Policy Number:   

Physician:        Phone:   

Dentist:       Phone:   

Specialist/Other:       Phone:   

General Health History

Select “Yes” or “No” for each question.  Explain any “Yes” answers below.

     Ever been hospitalized?                                  Ever had surgery? 

     Have chronic illness?                                       Recent infectious disease?

     Had a recent injury?                                         Asthma/Shortness of breath?

    Have diabetes?                                                  Had seizures?

    Had headaches?                                                Wear corrective eyewear?

    Had fainting or dizziness?                                 Passed out/chest pain during exercise?

    Had mononucleosis (mono) during past 12 months?

    Ever had back/joint problems?

    Have problems with diarrhea/constipation?

    Have any skin problems?

 

Please explain “Yes” answers from above.   

Allergies

      Does this camper have any known allergies?

If yes….

This camper is allergic to:   

 

Please describe specifics about the allergy and what reactions are seen.

Diet/Nutrition

Dutchess County Gymnastics Center requires that all campers bring their own food for snacks and lunches.  In any instance where a child does not have food for lunch, DCGC will provide a lunch from “The Bagel Shoppe” located in the same plaza.  The cost will be $15 for each meal provided.

Please describe any dietary restrictions that this camper may have.

We discourage the “trading” of any food between the campers due to food allergies.  We also ask that parents pack foods that are nut free as there are usually children that have allergies to nuts in every camp.

Mental, Emotional, and Social Health

Select “Yes” or “No” for each question.  Explain any “Yes” answers below.

Has the camper:

1.  Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)?

1.

2.  Ever been treated for emotional or behavioral difficulties or an eating disorder?

2.

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

3.

4.  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)

4.

Please explain “Yes” answers from above.

Medications

Dutchess County Gymnastics Center will not administer any prescribed medications without specific written consent from a Parent/Legal Guardian.  If a camper must take a prescription medicine during camp hours, the medication must be in the original bottle with the camper’s name, along with detailed instructions on how and when to administer the medicine, and whether the camper will need additional assistance when taking the medication.  If possible, please administer all medications before or after the scheduled camp.

Asthma/Inhaler

    Does this camper require an inhaler for Asthma? 

     Will the camper carry a rescue inhaler?

    Does this camper need assistance with the inhaler?

Other

Please let us know any other information that you feel would be useful for the staff to know about your child while at camp.

Parent/Guardian Acknowledgment and Authorization

This health history is correct and accurately reflects the health status of the camper to whom it pertains.  The person described has permission to participate in all camp activities except as noted by me and/or an examining physician.  I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations.  If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child.  I understand the information on this form will be shared on a “need to know” basis with camp staff.  I give permission to photocopy this form and provide any information to a treating physician.  I understand that I must provide detailed instructions with any medications that may need to be taken during camp hours.  I agree that my child is fully immunized for public school and is considered healthy enough to participate without restriction in physical education activities.

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Dutchess County Gymnastics Center https://dutchessgymnastics.com
Signature Certificate
Document name: Camp Registration/Health Form
Unique Document ID: b99231c6ff2e69602b711b02cfe9403b34aced92
Timestamp Audit
December 21, 2018 3:58 pm ESTCamp Registration/Health Form Uploaded by Jeremy Keilly - jeremy@dutchessgymnastics.com IP 73.253.197.116
December 26, 2018 2:50 pm ESTDutchess Gymnastics - info@dutchessgymnastics.com added by Jeremy Keilly - jeremy@dutchessgymnastics.com as a CC'd Recipient Ip: 174.44.103.52
December 27, 2018 9:31 am ESTDutchess Gymnastics - info@dutchessgymnastics.com added by Jeremy Keilly - jeremy@dutchessgymnastics.com as a CC'd Recipient Ip: 174.44.103.52
December 27, 2018 5:54 pm ESTDutchess Gymnastics - info@dutchessgymnastics.com added by Jeremy Keilly - jeremy@dutchessgymnastics.com as a CC'd Recipient Ip: 174.44.103.52
December 28, 2018 3:07 pm ESTDutchess Gymnastics - info@dutchessgymnastics.com added by Jeremy Keilly - jeremy@dutchessgymnastics.com as a CC'd Recipient Ip: 174.44.103.52
December 28, 2018 4:47 pm ESTDutchess Gymnastics - info@dutchessgymnastics.com added by Jeremy Keilly - jeremy@dutchessgymnastics.com as a CC'd Recipient Ip: 174.44.103.52
January 22, 2019 3:32 pm ESTDutchess Gymnastics - info@dutchessgymnastics.com added by Jeremy Keilly - jeremy@dutchessgymnastics.com as a CC'd Recipient Ip: 174.44.103.52
September 24, 2019 12:10 pm ESTDutchess Gymnastics - info@dutchessgymnastics.com added by Jeremy Keilly - jeremy@dutchessgymnastics.com as a CC'd Recipient Ip: 73.253.197.116