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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 time of retreat or have in his/her possession.

Please complete all fields before sending. This Form 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 use this form to send your child's Health and Safety Form, please follow these steps:

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

After you send the Form using email, this page reappears. You're done! Thank you.
                                                                                                                    ↓  Copy Form ↓ 

Step 4: Complete Health Form  | Step 5: Send Completed Health Form
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:   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

All rights reserved. 2004. For questions or problems with this form contact Kevin Lee, Web administrator