Text Box: Health History Form (required for campers, after school care and staff) The Metuchen Edison Woodbridge YMCA Edison Branch YMCA 1775 Oak Tree Road, Edison Name of Participant_____________________________Birth Date_____________ Home Address____________________________Town____________Zip_______ Sex M F Age as of June 1____________ Grade entering in Sept_______ Parent/Guardian Name_______________________Daytime Phone______________ Cell______________________ Beeper______________________ Parent/Guardian Name________________________Daytime Phone_____________ Cell______________________ Beeper______________________ If not available in an emergency, please notify: Name____________________________________Daytime Phone______________ Text Box: Health History Allergies (please list) Treatment ______________________________……………………__________________________ ______________________________…………………..__________________________ ______________________________…………………..__________________________ Dietary modifications________________________________________________ Disabilities________________________________________________________ Chronic/recurring illnesses____________________________________________ Current medications_________________________________________________ Activity limitations__________________________________________________ Any other known physical or mental conditions______________________________ Name of physician_______________________________ Phone (____)__________ Date of last physical examination____________________ This Health History is correct, so far as I know, and the person herein described has permission to engage in all prescribed activities except as noted. ____________ initial Emergency Authorization: I hereby give permission to medical personnel to order X-rays, routine tests, and treatment for me/my child. In the event that I cannot be reached in an emergency, I hereby give permission to the physician to hospitalize, secure proper treatment for, and to order injection, anesthesia, and/or surgery for me/my child as named above. This form may be photocopied. ______________________________________________ ________________________ signature of participant (parent/guardian if under 18 yrs) date PLEASE ATTACH A CURRENT COPY OF YOUR CHILD’S RECORD OF IMMUNIZATION. THIS FORM MUST BE NOTARIZED.