JYM Retreats Health and Safety Form

Dear Parents and Guardians:
This form must be on file when your child arrives for his/her first retreat. Once this form is on file with us, it may also serve for future retreats if information (especially HMO) has not changed. Please use one form per child. All health and safety information is considered confidential.  Please don't hesitate to speak with me directly on the phone if you feel that would be in your child's best interest.

Please complete all fields before sending. This Form may also be printed, filled out, and US Mailed  to: Kevin Lee, JYM Retreats, 48 Carlton Street, Dartmouth MA 02748-1622. If you have any questions, please contact Kevin.

Child's Name:
Date of Birth:
Month Day Year
Emergency contact person if we cannot reach you
Person’s relationship to child
Emergency Contact Phone
Cell Phone
Backup Phone

Email Address

Is child taking prescribed meds?

Can child self dose? (Yes/No)

As needed, please explain:

Any allergies, limitations or areas of need for us to be aware of? 
In a medical emergency, I give my permission for to receive emergency treatment as needed for the duration of the retreat.  I understand that I will be contacted immediately.  
Health Carrier:
Policy Number:
Today's Date:
Click to Send (Form sent to Kevin's email)