YOUNG LIFE CAPERNAUM PARENTAL OR GUARDIAN INTERVIEW

NOTE TO PARENTS/GUARDIAN: Young Life wants the camp experience to be a safe and healthy one. Thank you for taking the time to fill out this form; it will help us know how to best serve your son or daughter.

Camper’s Name:

Camper’s School:

What does the camper love to do?

Camper’s Extra Curricular Activities:

Camper’s Disability:

* If female and menstrual cycle begins at camp, how does she take care of herself?

* Is the camper aggressive? Y N If yes, how do you control his/her behavior?

* How does the camper deal with people he/she does not know?

* Is the camper’s speech understandable to people who do not know him/her? Y N

* Does the camper feed him/herself? Y N Anyfood restrictions?

* Is the camper on medication? Y N Has the medication been changed recently? Y N

CHECK ALL THAT APPLY:

Uses sign languageHas a shuntHas a rod supporting bones

Uses a language board Uses a hearing aidIs allergic to latex

Uses a wheelchair Uses a walker Uses toilet independently

Uses toilet with supervisionWearsadult briefs – any special instructions?

Uses signs to indicate need for toileting. Describe:

Anything else we should know to help us be able to serve your son or daughter?

EQUIPMENT USED:

Glasses Contact Lens Hearing Aid Helmet Wheelchair Walker Other

SPECIALIZED HEALTH CARE NEEDS:

Bowel/Bladder Training Assistance with Bathrooming Lifting/Positioning Other

CATHETERIZATION:

Clean Intermittent Catheterization External Catheter Other

OSTOMIES:

Ostomy Care Other

RESPIRATORY ASSISTANCE:

Percussion Postural Drainage Suctioning Other

SPECIMEN COLLECTING/TESTING:

Blood Glucose Insulin Pump Other

SPECIMEN COLLECTING/TESTING:

Blood Glucose Insulin Pump Other

CHRONIC, RECURRING AND SPECIAL HEALTH CONDITIONS

(Check all that apply and explain below)

Allergies Is Epi Pen needed? Y N Asthma

Arthritis Attention-Deficit/Hyperactivity Disorder Behavioral Challenges

Cerebral Palsy Cystic Fibrosis Developmental Challenges

Diabetes Down Syndrome Enuresis (involuntary urine discharge)

Head or Spinal Injury Hearing Impairment Heart Disease

Kidney Disease Muscular Dystrophy Seizures

Sickle Cell Disease (not trait) Spina Bifida Dental Problems

Explanation:

MEDICATION INFORMATION AND AUTHORIZATION Medications MUST be in their original prescription containers.

PRESCRIPTION NAME / DOSAGE / TIME TO BE GIVEN

Special Instructions:

I, parent/ guardian of , give my permission to the Young Life staff person or adult volunteer leader to administer my child’s medication in my absence. If needed, I also give permission for the staff person to administer personal hygiene care as follows:

SignatureDate

YL-6054 (Apr 2013) Printed in the U.S.A.