CYIA Medical Form (in Compliance with The Springs Medical Form) Step 1 Camper Name (First, Last, Middle Initial)Gender (as on birth certificate) Female Male Step 2 Student InformationAddress (House #, Street, City, State, Zip)Date of BirthParent/Legal Guardian (Primary Contact)Relationship to studentPrimary Phone NumberWork NumberParent emailParent/Legal GuardianRelationship to studentPrimary Phone NumberWork NumberEmergency Contact (other than parent)Relationship to studentEmergency Contact phone numberStep 3 Student's Health InformationAll information must be filled out. A health officer is on site at all times. It is our policy to contact the parent or guardian as soon as possible in the event of a serious accident or injury. If information jas changed on the day of registration, please see the health officer at that time. Please bring all medications in ORIGINAL CONTAINERS or you will not be allowed to leave the medication or vitamins at the camp. No exceptions. All prescriptions must have the child's name and correct dosage.Is your child free from infectious disease or conditions? Yes No Are the student's immunizations up to date? Yes No If "no" please explain.Does the camper have any restrictions? Yes No If "yes" please explain.Does the camper have any physical, mental, or other conditions that require special attention or medication? Yes No If "yes", please explain.Any past medical treatment that would be helpful for us to know? Yes No List ANY allergiesAny dietary needs that we should know about? Yes No If "yes", please explain.Insurance CompanyStep 4 MedicationList all medications, both prescribed and over the counter medications. These must be turned in to the health officer (except for rescue inhalers) and must be in the original containers.Step 5 OTC ApprovalPlease check all OTC medications that you approve to give to your camper as needed. Benadryl Claritin Zyrtec Hydrocortisone Cream Ibuprofen Lotrimin Cream Stool softener Tums Tylenol Zantec Consent Signature: Read and then sign. Your typed name holds the same weight as your signature)In case of medical emergency or general medical care, I give consent for medical treatment for the above named camper by authorized personnel. The camp carries secondary insurance. I understand that my child will be housed and use the bathroom in the same gender as specified on their birth certificate which reflects the gender listed on the application. Signature of Parent/Guardian
