/Join US

Join US

    Name*

    Sex

    male
    female

    Age*

    D.O.B*

    Name of Physician*

    Phone*

    Email ID*

    Do you have medical insurance?

    yes
    no

    Carrier

    Allergies

    (please check all that apply)

    Hay Fever*

    Ivy Poisoning, etc*.

    Insect Stings*

    Asthma*

    Penicillin

    Other Drugs*

    Other(please list)

    Are you taking any medications while at camp? Y/N

    yes
    no

    If so, what?*

    Medical Conditions

    (include conditions that may affect your participation)

    Heart Conditions*

    Epilepsy/Seizures*

    Diabetes*

    Vision/hearing impairment*

    Mental condition*

    Hepatitis*

    Blackout/dizzy spells*

    Arthritis*

    Infection*

    Pregnancy*

    Other

    Injuries

    (include conditions that may affect your participation)

    Strain/Sprain*

    Dislocation(s)*

    Back injury*

    Head injury*

    Fracture/break*

    Hernia*

    Other

    Are Immunizations Current?*

    Date of last tetanus shot?*

    Special Dietary considerations*

    Name*

    Home Phone*

    Mobile Phone*

    Work Phone*

    Acknowledgment of Risk and Safety

    Your signature below verifies that you:
    1)Have completed the Health Assessment form to the best of your knowledge;

    2)Recognize that there are inherent risks in any outdoor pursuit, and agree to follow instructions and
    directions given by your leaders, act prudently, use good judgment, and assume a shared responsibility for your safety;

    3)Understand that information may be collected and shared for the purposes of demonstrating
    outcomes or securing funding.

    4)Agree that your participation is voluntary, and further agree to indemnify, release and hold
    harmless the Foundation For Youth, Columbus Youth Camp, its directors, officers and
    employees from any and all claims or damages for any accident, injury or illness arising out of
    the use of facilities, equipment and/or participation in Columbus Youth Camp activities;

    5)Allow the Columbus Youth Camp Staff to provide routine health care, administer prescribed
    and parent provided OTC medications, and seek & provide emergency medical treatment where deemed necessary.

    Date*

    [recaptcha]