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JHYM Retreat Health and Safety Form-Via Email

Dear Parents and Guardians:
This form must be on file when your child arrives for his/her first retreat. If your child was with us the previous year, a new completed form is also required at the start of each program year.  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. We need to know what meds, prescribed or over-the-counter, your child may be taking at the time of the retreat or have in his/her possession.

Please complete all Health Info before sending. Health Info may also be printed, filled out, and US Mailed  to: Gretchen Baker Smith, JHYM Retreats, 14 Norcroft Street, Dartmouth MA 02748. If you have any questions, please contact Gretchen.

To send Health Info to Gretchen, please follow these steps:

1. Copy the entire list of requested Health Info below.    (How? Left click and scroll over Health Info list, then right click, and choose copy)
2. Click > Email Form To Gretchen Baker-Smith.
3. Paste the Health Info into the email that will open addressed to Gretchen.
4. After you copy it to your email, remember to complete the Heath Info requested before sending!. ☺
5. When the Health Info is completed, send it to me!

You're done! Thank you.

                                                                                                                    ↓  Please Copy Health Info Below and Email to Gretchen ↓ 

Child's Name:

Date of Birth (mo/day/yr):

Who can we call if we can't reach you? (neighbor, friend, relative):

Above person's relationship to your child:

Your cell phone:

Your home phone:

Backup phone # we can call:

Is child taking any prescribed meds? (Yes/No):

If yes to above, please list  meds?

Is your child taking any other meds at time of retreat?:

If yes to above, please list non-prescribed meds being taken:

First Retreat With Us? (yes/no):

Food Allergies: Is your child allergic to any foods? If so, explain in detail:

Does your child require a special diet? If so, please explain:

Is your child a vegetarian or vegan? If yes, please write "vegetarian" or "vegan": 

Does your child have other allergies? If so, explain in detail:

Other areas of limitations or needs that we should be aware of? (Yes/No/Will Call):

Name of person filling out this form (mom/dad, etc):

Street Address:

City, State, Zip:

Health Carrier:

Policy Number:

Today's Date:

In a medical emergency, I give my permission for my child to receive emergency treatment as needed for the duration of the retreat.
I understand that I will be contacted immediately.
Permission is granted: Please type your name:

Permission not granted: Please type your name:

Notes to Gretchen: