Please complete and sign this form. Teachers must return these forms to the Sherman Lake YMCA prior to the group’s arrival at camp. ALL INFORMATION IS KEPT CONFIDENTIAL. Sherman Lake YMCA Outdoor Center
To download the Integrated Education overnight information packet please go to the website 1)click on school programs 2)click on programs and activities 3)click on parent packet for overnight school groups
Registration and Health Information Form School Name: ____________________________________________ Grade:_________ Camper Information: Name of Student______________________________ Nickname (if any)___________________ Male or Female (please circle one) Age_______________ Birth date______________________
Home address___________________________________________________________________
Custodial Parent______________________________Relationship to camper________________ Phone (_____) ________________Business phone_____________ Email ___________________ In an EMERGENCY, please contact parent listed above or: Name:__________________________ Phone: ________________Relationship:_____________ Name:__________________________ Phone: ________________Relationship:_____________ Activities and Interests: What camp activities most interest your camper? ______________________________________ Are there any camp activities that the camper should not participate in? _____________________ Dietary concerns: (Circle only if apply) Diabetic Lactose Intolerance Vegetarian Picky Eater Behavior concerns: (Circle only if apply) Nervousness Sleep Walking Bedwetting Homesickness Psychiatric
Do you have any specific requests that you hope your camper will learn while at camp? ________ Camper’s swimming ability: (please circle one) Nonswimmer Fair Good Excellent Additional information/comments for counselor: ___________________________________________ ______________________________________________________________________________________ Health Information:
Past and/or present medical conditions: ______________________________________________ ______________________________________________________________________________ Allergies: yes____ no____ List____________________________________ Has your child been exposed to a communicable disease in the last three weeks? yes____ no____ List____________________________ Has your child ever had a seizure yes____ no____ Explain___________________________
Physical limitations or restrictions yes____ no____ List______________________________ Special dietary needs or restrictions yes____ no____ List____________________________ Additional health information, special medical needs, or concerns _________________________ ______________________________________________________________________________ Are your child’s immunizations up to date? yes____ no____ Date of last tetanus shot ____________Date of last physical exam ________________________ Family Physician______________________________ Phone (_____)_____________________ Family Dentist________________________________ Phone (_____)______________________ Orthodontist__________________________________ Phone (_____)______________________ In the case of unexpected aches and pains, may over the counter medications (Tylenol, Motrin, Benadryl, etc.) be given to your camper? ___ yes ___ no Do you have medical insurance? ___ yes ___ no Insurance company name ________________ Policy or certificate # ___________________________Phone (_____) _____________________
Medications: Please send all prescription medication that your child will need at camp, also including any regularly used over the counter medications. Send only the amount of medication needed while at camp. Prescription medication bottle must state the current dosage and schedule. Permission to dispense medication: (Please list all prescription and non-prescription): 1. MEDICATION: ____________________________Dose:____________________________ Days to be given: ______________________________ or circle ONLY AS NEEDED Circle time to be given: Breakfast Lunch Mid-afternoon Dinner Bedtime 2. MEDICATION: ____________________________Dose:____________________________ Days to be given: ______________________________ or circle ONLY AS NEEDED Circle time to be given: Breakfast Lunch Mid-afternoon Dinner Bedtime Parent Signature Required: This health history is correct to the best of my knowledge, and the person herein described has permission to engage in all camp activities except as noted. Authorization for Treatment: I hereby give permission to the medical personnel selected by the camp staff to order X-rays, routine test, treatment, and necessary transportation for my child or me. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp staff to secure and administer treatment, including hospitalization, for my child or me as named above. These completed forms may be photocopied for trips out of camp. In consideration for being allowed to participate in the YMCA’s programs, I agree to assume the risk of such activities and programs, and I further agree to hold harmless the Sherman Lake YMCA Camp and its staff members conducting the activities from any and all claims, suits, losses, or related causes of action for damages, including, but not limited to, such claims that my result from injury or death, accident or otherwise, during or arising in any way from the activities. I grant permission for my child or me to participate in all planned camp activities including out-of-camp trips by van or bus, hiking or horseback riding, understanding that competent leadership is provided. The YMCA is not responsible for lost, stolen, or damaged personal articles. I also authorize the Sherman Lake YMCA to have and use photographs, slides, or video tapes of me , my child, or my family as may be needed for its public relations programs. I acknowledge that this General Release of Liability of the Sherman Lake YMCA is binding on me personally and on my heirs, personal representatives, successors, and assigns. Parent/Staff Signature_____________________________________Date_____________ **Anyone under the age 18 must have a parent signature. Over the age 18: This form enables you to be treated in case of emergency. ***Please note: All School Personnel that plan to attend the Sherman Lake YMCA must fill out and sign this form.
Conference in Bolivia, 1999 ① Conference in Bolivia Feb 24thCase 52 yo M, married, farmerPresented by Dr. M., residentPast history； DM×2y. Pulm.TBC×1y(completed treatment for 8mo). Alcohol×17years. Present il ness(summarized briefly)；8days ago, he started to have a precordial pain with diaphoresis. The pain lasted 17 hours. He was given a sublingual drug at an outside clinic and he
GUIDELINES ON STRUCTURAL REGULARITY Note: This document aims at providing guidelines on the subject “structural regularity”, which may be used both from researchers and practical engineers. This version of the document is proposed by the research groups of the universities of Catania and Florence, Italy, as a basis of discussion for all the people interested to the subject. This version