camper pick-up authorization form - …ymcachgo.3cdn.net/a64faecb718a392bdd_8gm6bfyk8.pdfcamper...

CAMPER PICK-UP AUTHORIZATION FORM Please fill out a separate form for each camper.

Transportation To Camp: ___________________________________ Transportation From Camp: ___________________________________________

Please put DRIVING, STAYOVER, or the bus stop:

(Lattof, Irving Park, South Side, Indian Boundary)

Camper Name: ____________________________________________________________________________________ Session # ___________________

Please list the people authorized to pick up your child from camp or the bus, including yourself. Whoever picks your child up will be

asked to present a photo ID for verification. Please list more than one (1) person in the event that you are not able to pick up your

child on the day the session ends.

1. Authorized Adult _____________________________________________________________________________Contact # (_____________)______________________________


3. Authorized Adult _____________________________________________________________________________Contact # (_____________)______ ________________________


Parent/Guardian name printed ________________________________________________ Signature____________________________________________

Pick-up Signature: __________________________________________________________________ Date: ____________________________________________

(Only sign this line at the time of PICK-UP)

------------------------------------------------------------------------------------------------------------------

Do Not Cut Do Not Cut Do Not Cut Do Not Cut

CAMPER STORE ACCOUNT FORM

Please fill out a form for each camper. Credit Cards are the only acceptable form of payment.

Campers have the opportunity to shop in the camp store for clothing, souvenirs, etc. Camp Pinewood will track your child’s spending

and charge your credit card at the conclusion of their session. A copy or your camper’s store receipt with your credit card charge will

be sent home with your camper.

Camper Last Name ___________________________________ First Name ____________________________________________ Session # _____________

Maximum $ amount that can be charged by your child $__________________________________

(If not specified, we will allow your camper to spend up to a maximum of $75 for a 1 week session and $150 for a 2 week session)

Cardholder Name (please print)____________________________________________________________________________________________________________

Card Number ______________________ ______________________ ______________________ _______________________ Exp_______________/______________

Cardholder Signature________________________________________________________________________________________________________________________

WE DO NOT ACCEPT CA$H!

CAMPER INFORMATION FORM

For our staff to be the most helpful to your child in his/her adjustment to camp life and direct his/her growth and development, we are

asking that you complete the following form. This form is only shared with your camper’s counselors and administrative staff and will

be used in their best interest.

Camper Name: _______________________________________________________________________________ Session(s): __________________________________

Name Camper likes to be called: ______________________________________________ Fav. Food: ________________________________________________

Brothers: ______________________ Sisters: _______________________ Has the camper been away from home before: YES NO

Child lives with: Mother Father Guardian (specify): ______________________________________________________________________________________

Does your child have any nighttime concerns (bedwetting, sleepwalking, nightmares, etc.): YES NO

Explain: _____________________________________________________________________________________ ___________________________________________________

Any special needs we should be aware of? ________________________________________________________________ _______________________________

__________________________________________________________________________________________________________________________________________________

Any serious fears that your camper may have (Specify): ________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________

Camper’s major interests, hobbies and/or school activities? _________________________________________________________________________

_____________________________________________________________________________________________________________________________ _____________________

Is there any situation at home that may affect the child while at camp (ie. Recent death of family member/pet, moving, change in

family structure, recent illness/injury)? How can we best support your child in regards to this?

_____________________________________________________________________________________________________________________________ ____________________

______________________________________________________________________________________________________________ ___________________________________

Describe the camper’s social skills with his/her peers at school. Does the camper make friends easily? _______________________

_____________________________________________________________________________________________ _____________________________________________________

If your child “shuts down” at home, what are some techniques you use to help them open up? __________________________________

__________________________________________________________________________________________________________________________________________________

When a change of behavior is needed, what works best for you at home? (i.e. time out, activity restriction, etc.)

__________________________________________________________________________________________________________________________________________________

Are there any camp activities in which you do not wish your child to participate?

________________________________________________________________________________________________ __________________________________________________

What are the top three (3) expectations your child has for his/her session at Camp Pinewood this summer?

(1) ______________________________________________________________________________________________________________________________________________

(2) ______________________________________________________________________________________________________________________________________________

(3) ______________________________________________________________________________________________________________________________________________

Please list three (3) goals you have for your child at Camp Pinewood:

(1) ______________________________________________________________________________________________________________________________________________

(2) _________________________________________________________________________________________________________________________ _____________________

(3) ______________________________________________________________________________________________________________________________________________

Parent Letter (Optional - please attach): Parents are requested to write a brief description of their child highlighting their personality and

other information that would help the counselor in fulfilling his or her duties.

Camper Letter (Optional, Yet Strongly Encouraged - please attach): Each camper is asked to write a note to his or her counselor before

camp begins. In this way, our staff can read a little about his/her campers. Our counselors can then tailor the group activities and discussions

and know more about each camper in his or her cabin group. Returning campers should be encouraged to complete this letter with some

specific things they would like to do at camp this year including interests and experiences they hope to gain.

Camper Name: _______________________________________ Session#: _________ Date: _______________

Health History, Medication, and Examination Form (PAGE 1) ***Please complete this page fully for each camper***

Camper Birth Date: ______/________/________ Age at Camp: _____ Gender: ___ Male ___Female

Custodial Parent/Guardian: ________________________________ Home Phone: _______________________

Home Address: _____________________________________________________________________________ Street Address City State Zip

Work Phone: _______________________________ Cell Phone: _____________________________________

Second Parent/Guardian/Emergency Contact Name: _______________________________________________

Home Address: _____________________________________________________________________________

Phone: ___________________________________________________________________________________ Street Address City State Zip

Work Phone: _______________________________ Cell Phone: _____________________________________

If not available in an emergency, notify: ______________________________ Relationship: _______________

Home Phone: __________________ Work Phone: __________________ Cell Phone: ____________________

Insurance Information

Is the camper covered by Medical Insurance? _____Yes _____No

Name of Policy Holder: ____________________________ Policy Holder Birthday: _____/______/________

Carrier Name: _____________________ Group #: ______________________ Policy#____________________

Carrier Address/Phone:_______________________________________________________________________ Street Address City/State/Zip/Phone

Policy Holder Social Security Number or ID Number ____________________________________________

Important - The information below must be completed for attendance*

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. YMCA Camp Pinewood 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 of parents.

Parent/Guardian Signature: __________________________________________Date: ____________________

*If for religious reason you cannot sign this, contact the camp for a waiver, which must be signed.

Will the camper have any medication, prescription or non-prescription, over-the-counter drugs, inhalers, epipens,

vitamins, minerals, herbs, and/or medical procedures needed or provided at camp: ____ YES ____ NO

Does your camper have any Allergies: ____ YES ____ NO

If YES to either, please fill out PAGE 2 of this form.


Health History and Examination Form (PAGE 2) ***Please complete for each camper with any Medication and or Allergies***

Medication Procedures

- Please list all medication prescription or non-prescription, over-the-counter drugs, inhalers, epi-pens, vitamins,

minerals, herbs and or medical procedures taken regularly or as-needed basis by the camper.

- Leave in the original container, pack enough to last the entire stay at camp. Make sure that all of the above

listed and prescription drugs are in the original container that includes the physician name, medication name

and dosage/administration instructions.

- Put all medications into a sealed clear plastic bag labeled with the camper’s name and take it to the

check-in or the bus stop. Please DO NOT pack medications in your camper’s luggage.

This camper takes the following medications or needs the following medical procedures:

Medication: __________________________ Reason for taking: _____________________________________

Frequency: (Check One) ____ Daily ____ As-Needed ______ Other/Please Explain ______________________

Times: ___ Breakfast ____Lunch ____Dinner ____Bed Time ____ Other Time Please Explain______________

Other Dosage/Administration Instructions Comments:_____________________________________________

















Allergies/Medical Procedures: (please list any food, environmental, medication allergies or medical procedures)

__________________________________________________________________________________________

__________________________________________________________________________________________

If space is needed for any other medication or procedures, please print a second copy of this page and attach.


Health History and Examination Form (PAGE 3) ***Physician must complete for each camper if doctor signed physical is not attached***

Health Care Examination/Recommendations by Licensed Medical Personnel The Health Care Examination section must be completed by a licensed physician before attending camp. If the camper has had a doctor’s

examination within 24 months of their camp session, then that examination form may be attached in place of this page (may be obtained from

child’s school). Examination record must include information on current prescription and nonprescription drugs and medications,

immunization status, physical limitations, allergies, and any special health and behavioral considerations.

(Below is for Doctors Office Use Only)

Camper Name: ________________________________ I examined the individual on ____/_____/_____ (date)

The applicant is under the care of a physician for the following conditions:

_____Weight _____Blood Pressure _____Eyes _____Glasses _____Ears _____Nose _____Throat

_____Skin _____ Extremities _____Heart _____Lungs _____Abdomen _____Hernia

_____Teeth _____Posture/Spine _____Other: _________________________________________________

Explanation of any checked: __________________________________________________________________

Females: Menstrual History Normal _____________Special Considerations ____________________________

Recommendations and Restrictions at Camp:

Treatment to be continued at camp: _____________________________________________________________

Medically-prescribed meal plan/dietary restrictions: ________________________________________________

Medication Allergies: Describe reaction and management/treatment:

__________________________________________________________________________________________

Food Allergies / Dietary Restrictions: Describe reaction and management/treatment:

__________________________________________________________________________________________

Other Allergies Describe reaction and management/treatment:

__________________________________________________________________________________________

Restrictions / Limitation of camp activities (e.g. what cannot be done, what adaptations are necessary, etc.):

__________________________________________________________________________________________

Has the camper had or have any recent illness, mental illness, injury or infectious disease? ___Yes ___No

If yes, please explain: ________________________________________________________________________

Health History (if any checked please put the date of the last record incident)

_____Chicken Pox _____Ear Infections _____Migraines _____Mononucleosis _____Measles _____Nosebleeds

_____Convulsions _____Surgeries _____German Measles _____Asthma _____Dizziness _____ Heart Murmur _____Seizures _____

Behavior Issues _____Mumps _____ Diabetes _____ Eating Disorders Diabetes _____Rheumatic Fever

Other health or dental concerns or details of any of the above: _______________________________________

Immunization History (Please list dates as accurately as possible)

_____DPT Series _____Booster _____Tetanus Booster _____Hepatitis B Series _____Polio OPV (Sabin)

_____Booster _____MMR _____Tuberculin Test _____Other (please list): _______________________________________

I have examined the person described and have reviewed his/her health history. It is my opinion that the above named camper is

physically able to engage in camp activities, except as noted.

Physician Signature: _____________________________________________________________________________ Date: _____/______/________

Name (Physician/Health Care Facility): ___________________________________________________ Phone #:_____________________________

Address: ________________________________________________________________________________________________________________

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