Lynch/van Otterloo YMCA Summer Camps Emergency Authorization Form

Camper’s Name: ____________ ___________ DOB ______/______/______ Address: ___________________________________________________________ Town: _________________________________________ Parent/Guardian Name: Phone Numbers: Cell Parent/Guardian Name: Phone Numbers: Cell

___________ ____________________________________ Work

_____________________ _______________ ___________________ ____________ _____

____________________________________ Work

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EMERGENCY CONTACTS/AUTHORIZATION FOR RELEASE I give the Lynch/van Otterloo YMCA Summer Camp programs permission to contact in an emergency and/or release my child to the following people: Name: __ Relationship to child: ______________________ _______________ Cell Phone: ______________ ____________________________________ Work Phone: ________________________________________________ Name: Cell Phone:

______________

__ _ Relationship to child: ___________ _______________________ ____________________________________ Work Phone: ________________________________________________

FIRST AID CONSENT I authorize the Lynch/Van Otterloo YMCA Summer Camps Staff, who are trained on the basics of first aid and/or CPR, to administer first aid and/or CPR to my child when appropriate. I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize the staff of the YMCA of the North Shore to call an ambulance to transport my child to the nearest hospital and to secure the necessary medical treatment for my child.

____________________________________________________________ Parent/Guardian Signature

_____/______/______ Date

ALLERGIES/MEDICAL CONDITIONS CHECK ITEM THAT APPLIES TO YOUR CHILD:

MY CHILD HAS NO KNOWN ALLERGIES AND/OR CHRONIC HEALTH CARE CONDITIONS MY CHILD HAS ALLERGIES AND/OR CHRONIC HEALTH CARE CONDITIONS Name of Allergy/Chronic Health Care Condition: ___________________________________________________________________________________

If your child has an allergy or chronic health condition your child’s physician must complete an Authorization for Medication Form.

___________________________________________________________ Parent/Guardian Signature

_____/_______/_______ Date

HEALTH CARE PROVIDER INFORMATION Name of Provider: ________________________________________________________ Address: _________________________________________________________________ Phone: _____________________________________________________________

PHOTOGRAPH CONSENT FORM I, give permission for my child, to be photographed while attending the Lynch/van Otterloo YMCA Summer Camp Programs to appear in the following items: Camp Newsletters and/or YMCA promotional materials.

___________________________________________________________ Parent/Guardian Signature

_____/_______/_______ Date

Lynch/van Otterloo YMCA . 40 Leggs Hill Road . Marblehead, MA 01945 . 781-631-9622