Medform2010

Cheshire YMCA Developmental Travel Medical Information
(to be filled out by every student's parent or legal guardian & brought to the next meeting)

Personal Information:
Group Letter: ________
Father's Address: (if different from home address) Mother's Address: (if different from home address) Father's Employer: Insurance Information:
Do you carry Medical/Health Insurance?  Yes  No
If so, indicate Carrier: __________________________________________ Policy or Group #: _____________________
Name of Insurance Subscriber (Father/Mother, etc): ______________________________________________________

Medical Information: (Check al that apply)
Health History
Allergies
History of Seizures/Epilepsy, Black outs Other Medication or Antibiotic Al ergies Food Al ergies:  Peanut  Other Nuts (list) Motion Sickness
Does your student use an inhaler?  Yes  No Wil your student bring an inhaler on tour? Any Other Recent Serious Injuries/Hospitalizations Is your student a vegetarian?  Yes  No
Please explain any dietary restrictions or special diets: ___________________________________________
Name of dentist/orthodontist: _________________________________ Phone #: ______________________
Name of family physician: ____________________________________Phone #: ______________________
Last Tetanus immunization Date: ______________________________
Cheshire YMCA 32 Lake St. N. Swanzey NH 03431 - (603) 352 - 0447; FAX (603) 352 - 0516
Over The Counter Medications:

While we are on tour, we bring the fol owing over the counter stock medications. If you wish to give permission for your
student to be medicated if needed while on tour, please check any boxes that would apply:
Medication
Medication
All medications listed as needed
 Yes  No
 Yes  No I b uprofen / Advil / Motrin (pain, fever)  Yes  No Benadryl or generic equivalent (al ergy)  Yes  No
Please List All Current Medications Your Student Will Be Taking While On Tour:
Medication
Directions
Any Additional Comments or Pertinent Medical Information:

Emergency Information: (to be contacted if parents/guardians are unavailable)
Please provide ful name, ful address [street/town/phone number (area code and 7 digit #)] and relationship with student
1.
2.
3.
Student's Health/Accident Responsibility For Travelers

Safety, health consciousness, and accident prevention are constant concerns of the staff of this YMCA Travel
Programs….but accidents do periodically occur and participants periodical y become il , on tour as wel as at home. As
nearly al the families who participate in this YMCA's travel Program carry their own Health and Accident Insurance (i.e.
BC/BS) and when bil ed by hospitals, clinics or medical doctors, each family covers these responsibilities, it is wasteful for
this YMCA to duplicate family coverage and pass on additional expense. Whatever coverage we previously carried has
had low limits, disclaimers and exclusions so that coverage was minimal compared to Individual Family Plans.
Accordingly,
THE CHESHIRE YMCA DOES NOT CARRY ACCIDENT/ILLNESS/DEATH OR DISMEMBERMENT INSURANCE ON
ANY OF ITS TRAVELERS IN YMCA TRAVEL PROGRAMS. IT IS THIS YMCA'S POSITION THAT EACH TRAVELER'S
HEALTH IS THEIR OWN RESPONSIBILITY OR THAT OF HIS/HER RESPECTIVE FAMILY.
If a family self-insures or does not have any medical coverage, they recognize that we do not carry health and accident
insurance and they recognize that each participant's medical expenses are their family's responsibility should such
expenses be incurred.
As parent/guardian of the student on this form, I have read and understand the program information and the
health/accident policy. In case of emergency, I hereby give my permission for emergency care and treatment.

Parent/Guardian Signature
Cheshire YMCA 32 Lake St. - N. Swanzey NH 03431 - (603) 352 - 0447; FAX (603) 352 - 0516

Source: http://cheshireymca.org/neht-nw/files/2012/09/medform2010.pdf