Youth Information Form Youth Information Form https://www.cmc.org/youth/youth-information-youth-programs-forms/youth-information-form https://www.cmc.org/logo.png Youth Information Form Youth Information Form = Required Dear Families, Thank you for taking the time to complete the Youth Information Form. Colorado Mountain Club strives to be a welcoming and inclusive organization. We believe that our program participants benefit from sharing meaningful experiences in a positive outdoor environment with others who bring a diversity of skills, life experiences, personalities, perspectives and beliefs to the program. Many youth have life situations that may influence their experience in Colorado Mountain Club programming. These situations may be medical, physical, dietary, religious, emotional, family-related, school-related or trauma-related. In order to best serve each youth, we request that parents/guardians share this information with us on this form. Colorado Mountain Club is an Outdoor Education organization, and we strive to provide the best possible learning environment so that participants have the best chance of success in skill– and community-building. This includes maintaining physical and emotional comfort and safety for participants. Colorado Mountain Club will make every effort to accommodate any special requests associated with the circumstances listed on this form. In the event that we cannot make accommodations, we will communicate that in advance with the family, and the youth will have the option to participate without accommodation or to forego participation. Colorado Mountain Club takes privacy and confidentiality seriously. Information on this form will be shared ONLY with Colorado Mountain Club Youth Program Staff and Instructors for the activity or activities in which the youth is participating. Information will not be disclosed to any other individuals except as necessary for the safety of the youth and as communicated with the youth and family in advance of disclosure. Youth may have the option to forego participation in lieu of disclosure. Contact Information Youth Information First Name Last Name Child's Preferred Name Birth Date Age T-Shirt Size (please indicate if youth or adult size) Gender Preferred Pronoun(s) Current Grade Level School Name Race/Ethnicity (we use this to measure the accessibility of our programs to all) Free/Reduced Lunch Eligibility - Is your child eligible for the free or reduced lunch program (we use this to measure the accessibility of our programs for all and to make sure we are able to provide adequate financial assistance to those in need)? yesno Address Street City State Postal Code Phone Number Parent/Guardian 1 Parent/Guardian 2 Emergency Contact (Local) PERMISSION TO PICK UP PERMISSIONS Photo Release I hereby give full consent to the CMC staff to photograph my child and/or publish any photographs or videos in which my child appears, for educational or promotional use. I agree they may be used for public display and/or publication for nonprofit purposes. yesno Notes Health Information Medical History Does your child have a history of any of the following health or medical conditions? yesno Asthma yesno Ear Infections yesno Seizure Disorder yesno Developmental Disorders yesno GI Disorders yesno Heart Problems yesno Diabetes yesno Psychiatric Diagnosis yesno ADD/ADHD yesno Muscular/Skeletal Injury yesno Significant life event(s) that continues to effect their life (history of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, etc.) yesno Other Please provide any additional details regarding your child's health and medical history. If you checked any of the above conditions, please provide further explanation, or list and explain any additional considerations not included above. Please detail any additional emotional, behavioral, or other support needed for your child. Please list any dietary restrictions or needs: Allergies Please list all known allergies: Allergy Usual Reaction Treatment Allergy Usual Reaction Treatment Allergy Usual Reaction Treatment Allergy Usual Reaction Treatment Immunizations Please list the date of the most recent immunization or booster for those listed below. While this is not required to complete the form, it is helpful information to provide medical personnel in the event of an injury or illness. Chickenpox Diphtheria Hepatitis B Measles Mumps Rubella Pertussis Polio Tetanus HIB PCP Negative TB Test Has the youth ever tested positive for Tuberculosis? yesno If so, when? If your child has not been fully immunized, please sign the following statement: I understand and accept the risks to my child from not being fully immunized. Parent/Guardian Initials Date insurance information It is the responsibility of every parent or legal guardian to provide the participant's accident and health coverage while participating in Colorado Mountain Club activities. Colorado Mountain Club does not provide any accident or health coverage for its participants. Is the participant covered by medical/hospital insurance? yesno authorization for treatment This health history is correct to the extent of my knowledge, and my child has permission to engage in all prescribed activities. I hereby give permission to the First Aid or medical personnel selected by Colorado Mountain Club to provide treatment according to their assessment of my child’s needs. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by a Colorado Mountain Club Leader to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for my child as named above. I understand that Colorado Mountain Club does not provide emergency transportation and I authorize transportation by ambulance according to the judgment of the staff. I understand the program fees do not include health and accident insurance and I will be responsible for any and all charges incurred in obtaining prompt medical attention. This completed form may be printed for trips off of Colorado Mountain Club's property. Parent/Guardian Initials Date In the event of injury or illness, Colorado Mountain Club leaders will provide basic first aid in the field according to their training and certification level, and if needed will transport the youth by ambulance to the nearest definitive care facility. Do you have any specific instructions regarding medical care for the youth participant? yesno over-the-counter (otc) medication authorization As part of Colorado Mountain Club's programs, youth may spend 1-10 days in the care of Colorado Mountain Club's Staff and Volunteers, away from parents and guardians. While we promote a healthy environment by ensuring youth are fed and hydrated, and by avoiding extreme conditions when possible, there are times when a youth’s comfort and ability to fully participate can be significantly improved with over-the-counter (OTC) medication. Examples include headaches, nausea, allergies, minor injuries and menstrual cramps. I give permission for Colorado Mountain Club staff and volunteers to administer sunscreen, hand sanitizer and/or over-the-counter medications to my child as needed at their discretion. Colorado Mountain Club staff and volunteers will never administer a dosage that is greater than the dosage recommended on the medication directions for use. I assert that my child has no known allergies to any brands of these products, and acknowledge that allergies can develop at any time. I hereby give representatives of Colorado Mountain Club permission to administer to my child any brand of any of the following non-prescription over-the-counter medications: yesno Sunscreen yesno Hand Sanitizer yesno Ibuprofen yesno Acetaminophen yesno Diphenhydramine HCl (antihistamine found in brands like Benadryl) yesno Antacid or Anti-diarrheal (like Tums or Pepto Bismol) yesno Topical Antihistamine yesno Topical Antibiotic yesno Cold or Allergy Medication Notes prescription medication All prescription medications must be in their original bottle, labeled with the child's first and last name, and must be current (not expired). All controlled medication and medication requiring hypodermic needle administration (with the exception of Epipens which may be carried by the youth) must be kept in a zip lock bag or other container with accompanying doctor's orders, and must be stored with Colorado Mountain Club Staff or designated volunteer leaders. Youth may carry non-controlled "as needed" (PRN) prescription medications such as Epipens and Albuterol inhalers with parent/guardian permission. Click on the arrow next to each section to add a medication. Prescription Medication 1 Name of Medication Controlled drug? yesno Will the youth carry the medication and self-administer? yesno Dose Method (eg. oral, topical, injection) Times of Administration (eg. TID, BID, PRN, Breakfast/Dinner) If PRN (as needed), describe when this medication should be taken Relevant side effects of medication Plan for management of side effects What happens if this medication is NOT taken? Prescription Medication 2 Name of Medication Controlled drug? yesno Will the youth carry the medication and self-administer? yesno Dose Method (eg. oral, topical, injection) Times of Administration (eg. TID, BID, PRN, Breakfast/Dinner) If PRN (as needed), describe when this medication should be taken Relevant side effects of medication Plan for management of side effects What happens if this medication is NOT taken? Prescription Medication 3 Name of Medication Controlled drug? yesno Will the youth carry the medication and self-administer? yesno Dose Method (eg. oral, topical, injection) Times of Administration (eg. TID, BID, PRN, Breakfast/Dinner) If PRN (as needed), describe when this medication should be taken Relevant side effects of medication Plan for management of side effects What happens if this medication is NOT taken? Prescription Medication 4 Name of Medication Controlled drug? yesno Will the youth carry the medication and self-administer? yesno Dose Method (eg. oral, topical, injection) Times of Administration (eg. TID, BID, PRN, Breakfast/Dinner) If PRN (as needed), describe when this medication should be taken Relevant side effects of medication Plan for management of side effects What happens if this medication is NOT taken? Prescription Medication 5 Name of Medication Controlled drug? yesno Will the youth carry the medication and self-administer? yesno Dose Method (eg. oral, topical, injection) Times of Administration (eg. TID, BID, PRN, Breakfast/Dinner) If PRN (as needed), describe when this medication should be taken Relevant side effects of medication Plan for management of side effects What happens if this medication is NOT taken? Prescription Medication 6 Name of Medication Controlled drug? yesno Will the youth carry the medication and self-administer? yesno Dose Method (eg. oral, topical, injection) Times of Administration (eg. TID, BID, PRN, Breakfast/Dinner) If PRN (as needed), describe when this medication should be taken Relevant side effects of medication Plan for management of side effects What happens if this medication is NOT taken? over-the-counter (otc) medication In addition to over-the-counter (OTC) medication Colorado Mountain Club leaders may carry (see OTC Medication Authorization section above), parents may send OTC Medication with their children to Colorado Mountain Club programs, but must list them here. All medications, including OTC Medications must be in their original bottle, labeled with the child's first and last name, and must be current (not expired). Colorado Mountain Club leaders will distribute parent-indicated dosage or recommended dosage on label, whichever is less. Children aged 14+ may carry their own OTC medication and self-administer with parent permission. Any medications not listed on this form will be confiscated and returned to the parents/guardians. Click on the arrow next to each section to add an over-the-counter medication. OTC Medication 1 Name of Medication If the youth is aged 14+, will they carry the medication and self-administer? yesno Dose Describe when this medication should be taken OTC Medication 2 Name of Medication If the youth is aged 14+, will they carry the medication and self-administer? yesno Dose Describe when this medication should be taken OTC Medication 3 Name of Medication If the youth is aged 14+, will they carry the medication and self-administer? yesno Dose Describe when this medication should be taken OTC Medication 4 Name of Medication If the youth is aged 14+, will they carry the medication and self-administer? yesno Dose Describe when this medication should be taken OTC Medication 5 Name of Medication If the youth is aged 14+, will they carry the medication and self-administer? yesno Dose Describe when this medication should be taken OTC Medication 6 Name of Medication If the youth is aged 14+, will they carry the medication and self-administer? yesno Dose Describe when this medication should be taken additional information How did you hear about Colorado Mountain Club's Youth Programs? What do you hope your child gets out of this program? What is your goal for them? Does your child receive any special services at school? yesno Please describe anything we can do to help your child be successful in our programs. Are there any recent adjustments or family situations that may be impacting your child? yesno Are there any religious accommodations you would like us to make for your child? yesno Does your child have any short-term or long-term physical limitations? yesno Are there any specific accommodations you would like to request that have not already been listed on this form? yesno Is there anything else you would like us to know about your child? Are there any activities in which you do not want your child to participate in? Attachments attach documents needed per your program's requirements. check with your program leader if you're unsure which documents are needed. Most file types are supported, including .pdf and .jpg files, allowing you to scan a document or upload an image from your phone or other device. Heath Care Provider-Signed Health Form - Please present a document confirming a physical examination, which has been performed within the preceding twenty-four (24) months from the first day of attendance at camp by a health care provider, which includes any physical problems which would limit the camper's activity, and any special care which the child will need. The form must be signed by the child's Primary Care Provider. Immunization Record - Please attach your child's immunization record. If you do not have one, you can request one here. If you need to file exemption, please complete and attach a medical or non-medical exemption form found here. Medication Administration Form - Please download, complete, and attach this form if your child takes medication that will need to be administered during the program. Asthma Care Plan Form - Please download, complete, and attach this form if your child has asthma. Allergy Care Plan Form - Please download, complete, and attach this form if your child has allergies. Thank you for completing this form! We look forward to meeting your family !
Youth Information Form Youth Information Form https://www.cmc.org/youth/youth-information-youth-programs-forms/youth-information-form https://www.cmc.org/logo.png Youth Information Form Youth Information Form = Required Dear Families, Thank you for taking the time to complete the Youth Information Form. Colorado Mountain Club strives to be a welcoming and inclusive organization. We believe that our program participants benefit from sharing meaningful experiences in a positive outdoor environment with others who bring a diversity of skills, life experiences, personalities, perspectives and beliefs to the program. Many youth have life situations that may influence their experience in Colorado Mountain Club programming. These situations may be medical, physical, dietary, religious, emotional, family-related, school-related or trauma-related. In order to best serve each youth, we request that parents/guardians share this information with us on this form. Colorado Mountain Club is an Outdoor Education organization, and we strive to provide the best possible learning environment so that participants have the best chance of success in skill– and community-building. This includes maintaining physical and emotional comfort and safety for participants. Colorado Mountain Club will make every effort to accommodate any special requests associated with the circumstances listed on this form. In the event that we cannot make accommodations, we will communicate that in advance with the family, and the youth will have the option to participate without accommodation or to forego participation. Colorado Mountain Club takes privacy and confidentiality seriously. Information on this form will be shared ONLY with Colorado Mountain Club Youth Program Staff and Instructors for the activity or activities in which the youth is participating. Information will not be disclosed to any other individuals except as necessary for the safety of the youth and as communicated with the youth and family in advance of disclosure. Youth may have the option to forego participation in lieu of disclosure. Contact Information Youth Information First Name Last Name Child's Preferred Name Birth Date Age T-Shirt Size (please indicate if youth or adult size) Gender Preferred Pronoun(s) Current Grade Level School Name Race/Ethnicity (we use this to measure the accessibility of our programs to all) Free/Reduced Lunch Eligibility - Is your child eligible for the free or reduced lunch program (we use this to measure the accessibility of our programs for all and to make sure we are able to provide adequate financial assistance to those in need)? yesno Address Street City State Postal Code Phone Number Parent/Guardian 1 Parent/Guardian 2 Emergency Contact (Local) PERMISSION TO PICK UP PERMISSIONS Photo Release I hereby give full consent to the CMC staff to photograph my child and/or publish any photographs or videos in which my child appears, for educational or promotional use. I agree they may be used for public display and/or publication for nonprofit purposes. yesno Notes Health Information Medical History Does your child have a history of any of the following health or medical conditions? yesno Asthma yesno Ear Infections yesno Seizure Disorder yesno Developmental Disorders yesno GI Disorders yesno Heart Problems yesno Diabetes yesno Psychiatric Diagnosis yesno ADD/ADHD yesno Muscular/Skeletal Injury yesno Significant life event(s) that continues to effect their life (history of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, etc.) yesno Other Please provide any additional details regarding your child's health and medical history. If you checked any of the above conditions, please provide further explanation, or list and explain any additional considerations not included above. Please detail any additional emotional, behavioral, or other support needed for your child. Please list any dietary restrictions or needs: Allergies Please list all known allergies: Allergy Usual Reaction Treatment Allergy Usual Reaction Treatment Allergy Usual Reaction Treatment Allergy Usual Reaction Treatment Immunizations Please list the date of the most recent immunization or booster for those listed below. While this is not required to complete the form, it is helpful information to provide medical personnel in the event of an injury or illness. Chickenpox Diphtheria Hepatitis B Measles Mumps Rubella Pertussis Polio Tetanus HIB PCP Negative TB Test Has the youth ever tested positive for Tuberculosis? yesno If so, when? If your child has not been fully immunized, please sign the following statement: I understand and accept the risks to my child from not being fully immunized. Parent/Guardian Initials Date insurance information It is the responsibility of every parent or legal guardian to provide the participant's accident and health coverage while participating in Colorado Mountain Club activities. Colorado Mountain Club does not provide any accident or health coverage for its participants. Is the participant covered by medical/hospital insurance? yesno authorization for treatment This health history is correct to the extent of my knowledge, and my child has permission to engage in all prescribed activities. I hereby give permission to the First Aid or medical personnel selected by Colorado Mountain Club to provide treatment according to their assessment of my child’s needs. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by a Colorado Mountain Club Leader to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for my child as named above. I understand that Colorado Mountain Club does not provide emergency transportation and I authorize transportation by ambulance according to the judgment of the staff. I understand the program fees do not include health and accident insurance and I will be responsible for any and all charges incurred in obtaining prompt medical attention. This completed form may be printed for trips off of Colorado Mountain Club's property. Parent/Guardian Initials Date In the event of injury or illness, Colorado Mountain Club leaders will provide basic first aid in the field according to their training and certification level, and if needed will transport the youth by ambulance to the nearest definitive care facility. Do you have any specific instructions regarding medical care for the youth participant? yesno over-the-counter (otc) medication authorization As part of Colorado Mountain Club's programs, youth may spend 1-10 days in the care of Colorado Mountain Club's Staff and Volunteers, away from parents and guardians. While we promote a healthy environment by ensuring youth are fed and hydrated, and by avoiding extreme conditions when possible, there are times when a youth’s comfort and ability to fully participate can be significantly improved with over-the-counter (OTC) medication. Examples include headaches, nausea, allergies, minor injuries and menstrual cramps. I give permission for Colorado Mountain Club staff and volunteers to administer sunscreen, hand sanitizer and/or over-the-counter medications to my child as needed at their discretion. Colorado Mountain Club staff and volunteers will never administer a dosage that is greater than the dosage recommended on the medication directions for use. I assert that my child has no known allergies to any brands of these products, and acknowledge that allergies can develop at any time. I hereby give representatives of Colorado Mountain Club permission to administer to my child any brand of any of the following non-prescription over-the-counter medications: yesno Sunscreen yesno Hand Sanitizer yesno Ibuprofen yesno Acetaminophen yesno Diphenhydramine HCl (antihistamine found in brands like Benadryl) yesno Antacid or Anti-diarrheal (like Tums or Pepto Bismol) yesno Topical Antihistamine yesno Topical Antibiotic yesno Cold or Allergy Medication Notes prescription medication All prescription medications must be in their original bottle, labeled with the child's first and last name, and must be current (not expired). All controlled medication and medication requiring hypodermic needle administration (with the exception of Epipens which may be carried by the youth) must be kept in a zip lock bag or other container with accompanying doctor's orders, and must be stored with Colorado Mountain Club Staff or designated volunteer leaders. Youth may carry non-controlled "as needed" (PRN) prescription medications such as Epipens and Albuterol inhalers with parent/guardian permission. Click on the arrow next to each section to add a medication. Prescription Medication 1 Name of Medication Controlled drug? yesno Will the youth carry the medication and self-administer? yesno Dose Method (eg. oral, topical, injection) Times of Administration (eg. TID, BID, PRN, Breakfast/Dinner) If PRN (as needed), describe when this medication should be taken Relevant side effects of medication Plan for management of side effects What happens if this medication is NOT taken? Prescription Medication 2 Name of Medication Controlled drug? yesno Will the youth carry the medication and self-administer? yesno Dose Method (eg. oral, topical, injection) Times of Administration (eg. TID, BID, PRN, Breakfast/Dinner) If PRN (as needed), describe when this medication should be taken Relevant side effects of medication Plan for management of side effects What happens if this medication is NOT taken? Prescription Medication 3 Name of Medication Controlled drug? yesno Will the youth carry the medication and self-administer? yesno Dose Method (eg. oral, topical, injection) Times of Administration (eg. TID, BID, PRN, Breakfast/Dinner) If PRN (as needed), describe when this medication should be taken Relevant side effects of medication Plan for management of side effects What happens if this medication is NOT taken? Prescription Medication 4 Name of Medication Controlled drug? yesno Will the youth carry the medication and self-administer? yesno Dose Method (eg. oral, topical, injection) Times of Administration (eg. TID, BID, PRN, Breakfast/Dinner) If PRN (as needed), describe when this medication should be taken Relevant side effects of medication Plan for management of side effects What happens if this medication is NOT taken? Prescription Medication 5 Name of Medication Controlled drug? yesno Will the youth carry the medication and self-administer? yesno Dose Method (eg. oral, topical, injection) Times of Administration (eg. TID, BID, PRN, Breakfast/Dinner) If PRN (as needed), describe when this medication should be taken Relevant side effects of medication Plan for management of side effects What happens if this medication is NOT taken? Prescription Medication 6 Name of Medication Controlled drug? yesno Will the youth carry the medication and self-administer? yesno Dose Method (eg. oral, topical, injection) Times of Administration (eg. TID, BID, PRN, Breakfast/Dinner) If PRN (as needed), describe when this medication should be taken Relevant side effects of medication Plan for management of side effects What happens if this medication is NOT taken? over-the-counter (otc) medication In addition to over-the-counter (OTC) medication Colorado Mountain Club leaders may carry (see OTC Medication Authorization section above), parents may send OTC Medication with their children to Colorado Mountain Club programs, but must list them here. All medications, including OTC Medications must be in their original bottle, labeled with the child's first and last name, and must be current (not expired). Colorado Mountain Club leaders will distribute parent-indicated dosage or recommended dosage on label, whichever is less. Children aged 14+ may carry their own OTC medication and self-administer with parent permission. Any medications not listed on this form will be confiscated and returned to the parents/guardians. Click on the arrow next to each section to add an over-the-counter medication. OTC Medication 1 Name of Medication If the youth is aged 14+, will they carry the medication and self-administer? yesno Dose Describe when this medication should be taken OTC Medication 2 Name of Medication If the youth is aged 14+, will they carry the medication and self-administer? yesno Dose Describe when this medication should be taken OTC Medication 3 Name of Medication If the youth is aged 14+, will they carry the medication and self-administer? yesno Dose Describe when this medication should be taken OTC Medication 4 Name of Medication If the youth is aged 14+, will they carry the medication and self-administer? yesno Dose Describe when this medication should be taken OTC Medication 5 Name of Medication If the youth is aged 14+, will they carry the medication and self-administer? yesno Dose Describe when this medication should be taken OTC Medication 6 Name of Medication If the youth is aged 14+, will they carry the medication and self-administer? yesno Dose Describe when this medication should be taken additional information How did you hear about Colorado Mountain Club's Youth Programs? What do you hope your child gets out of this program? What is your goal for them? Does your child receive any special services at school? yesno Please describe anything we can do to help your child be successful in our programs. Are there any recent adjustments or family situations that may be impacting your child? yesno Are there any religious accommodations you would like us to make for your child? yesno Does your child have any short-term or long-term physical limitations? yesno Are there any specific accommodations you would like to request that have not already been listed on this form? yesno Is there anything else you would like us to know about your child? Are there any activities in which you do not want your child to participate in? Attachments attach documents needed per your program's requirements. check with your program leader if you're unsure which documents are needed. Most file types are supported, including .pdf and .jpg files, allowing you to scan a document or upload an image from your phone or other device. Heath Care Provider-Signed Health Form - Please present a document confirming a physical examination, which has been performed within the preceding twenty-four (24) months from the first day of attendance at camp by a health care provider, which includes any physical problems which would limit the camper's activity, and any special care which the child will need. The form must be signed by the child's Primary Care Provider. Immunization Record - Please attach your child's immunization record. If you do not have one, you can request one here. If you need to file exemption, please complete and attach a medical or non-medical exemption form found here. Medication Administration Form - Please download, complete, and attach this form if your child takes medication that will need to be administered during the program. Asthma Care Plan Form - Please download, complete, and attach this form if your child has asthma. Allergy Care Plan Form - Please download, complete, and attach this form if your child has allergies. Thank you for completing this form! We look forward to meeting your family !