CENTRAL CONNECTICUT COAST YMCA Summer Camp

HAMDEN/NORTH HAVEN YMCA CAMP MOUNTAIN LAUREL2020 Summer Camp Transportation Permission FormI hereby give permission for my child,, for emergency situationswhen the camp needs to be evacuated for the safety of the children.In the event of an emergency and I cannot be reached please call:at(Emergency Contact)(Phone Number)I prefer my child to be taken to hospital and in the eventthat my child requires emergency medical attention the following physician should be notified.(Physician’s Name and number)Signature of Parent/ GuardianDateHAMDEN/NORTH HAVEN YMCA1605 Sherman Avenue, Hamden, CT 06514P 203 248 6361 F 203 281 4858 W hnhymca.org

CENTRAL CONNECTICUT COAST YMCASummer Camp Behavior Contract for Participants, Parents, Families and CampersEXPECTIONS Show respect by treating other children and adults the way I would want to be treated. Be honest, will always tell the truth about actions and feelings. Be a friend that others can trust. Demonstrate caring by helping others and treating them kindly. Take responsibility for my own behavior and accept the consequences for my actions. To be free from cruel teasing and insults. Have a safe, calm, clean and orderly environment. Make mistakes without being ridiculed by others. Seek help from those that are there to help. Talk with Camp Staff when frustrated or feel mistreated. Be treated with dignity and respect by everyone. Use appropriate, acceptable language, don’t talk back or use obscene, threating language or speak in an unkind manner. Avoid fights or verbal abuse. Be fair and accepting of others eager to join any activity. Work and play safely. Be kind, considerate, helpful, and respectful toward others. Follow directions and listen attentively while participating in activities. Share equipment and materials fairly and use them properly. Respect property, especially things that do not belong to me. Cooperate with others who are there to help. Speak up when witnessing unfairness or offensive language or behavior of others. Be a good sport whether I win or lose. Be truthful with everyone.CONSEQUENCES Letter of discipline for talking back, destroying property, bullying children, disrupting the program, refusing obey. Parentwill be required to sign these reports acknowledging that they have read the report. After three reports child and parentmay be required to meet with the Camp Leadership Staff. Letter of discipline and immediately suspended for a minimum of one day for hitting, kicking, biting, spitting, scratching,swearing, making degrading or racial remarks, or leaving the group. Parents may be required to meet with the CampDirector before the child can return to the program. Camp services may also be terminated if the parent is physically or verbally abusive to a staff member. It is our desirethat every child enjoys his/her experience in the program. Participation in the Summer Camp program may be limited or discontinued if this contract is not followed.SOME BEHAVIORS MAY WARRANT OUR SKIPPING PROCEDURES DEPENDING UPON THE SEVERITY OF THE INAPPROPRIATE BEHAVIOR.Parent/Guardian SignatureChild/Participant SignatureDateCENTRAL CONNECTICUT COAST YMCA1240 Chapel Street, New Haven, CT 06511P 203 777 9622 F 203 773 8950 W cccymca.org05/29/2020

CONCUSSION Information SheetThis sheet has information to help protect your children or teens fromconcussion or other serious brain injury. Use this information at your children’sor teens’ games and practices to learn how to spot a concussion and what todo if a concussion occurs.What Is a Concussion? Plan ahead. What do you want yourA concussion is a type of traumatic brain injury—or TBI—causedby a bump, blow, or jolt to the head or by a hit to the body thatcauses the head and brain to move quickly back and forth. Thisfast movement can cause the brain to bounce around or twist inthe skull, creating chemical changes in the brain and sometimesstretching and damaging the brain cells.child or teen to know about concussion?How Can I Spot a Possible Concussion?How Can I Help Keep My Children orTeens Safe?Children and teens who show or report one or more of the signsand symptoms listed below—or simply say they just “don’t feelright” after a bump, blow, or jolt to the head or body—may havea concussion or other serious brain injury.Sports are a great way for children and teens to stay healthy andcan help them do well in school. To help lower your children’sor teens’ chances of getting a concussion or other serious braininjury, you should: Help create a culture of safety for the team.› Work with their coach to teach ways to lower the chancesof getting a concussion.Talk with your children or teens about concussion andask if they have concerns about reporting a concussion.Talk with them about their concerns; emphasize theimportance of reporting concussions and taking time torecover from one.Signs Observed by Parents or Coaches Appears dazed or stunned. Forgets an instruction, is confused about an assignment orposition, or is unsure of the game, score, or opponent. Moves clumsily. Answers questions slowly. Loses consciousness (even briefly). Shows mood, behavior, or personality changes. Can’t recall events prior to or after a hit or fall.Symptoms Reported by Children and TeensEnsure that they follow their coach’s rules for safety andthe rules of the sport. Headache or “pressure” in head.Tell your children or teens that you expect them topractice good sportsmanship at all times. Balance problems or dizziness, or double or blurry vision. When appropriate for the sport or activity, teach yourchildren or teens that they must wear a helmet to lower thechances of the most serious types of brain or head injury.However, there is no “concussion-proof” helmet. So, evenwith a helmet, it is important for children and teens to avoidhits to the head. Nausea or vomiting. Bothered by light or noise. Feeling sluggish, hazy, foggy, or groggy. Confusion, or concentration or memory problems. Just not “feeling right,” or “feeling down.”Talk with your children and teens about concussion. Tell them to report their concussionsymptoms to you and their coach right away. Some children and teens think concussions aren’t serious or worrythat if they report a concussion they will lose their position on the team or look weak. Be sure to remind them thatit’s better to miss one game than the whole season.To learn more, go to www.cdc.gov/HEADSUP

Concussions affect each child and teen differently. While most children andteens with a concussion feel better within a couple of weeks, some will have symptoms formonths or longer. Talk with your children’s or teens’ health care provider if their concussionsymptoms do not go away or if they get worse after they return to their regular activities.What Are Some More Serious DangerSigns to Look Out For?What Should I Do If My Childor Teen Has a Possible Concussion?In rare cases, a dangerous collection of blood (hematoma) mayform on the brain after a bump, blow, or jolt to the head or bodyand can squeeze the brain against the skull. Call 9-1-1 or takeyour child or teen to the emergency department right away if,after a bump, blow, or jolt to the head or body, he or she hasone or more of these danger signs:As a parent, if you think your child or teen may have aconcussion, you should: One pupil larger than the other. Drowsiness or inability to wake up. A headache that gets worse and does not go away. Slurred speech, weakness, numbness, or decreasedcoordination. Repeated vomiting or nausea, convulsions or seizures(shaking or twitching). Unusual behavior, increased confusion, restlessness,or agitation. Loss of consciousness (passed out/knocked out). Even abrief loss of consciousness should be taken seriously.Children and teens who continue to play whilehaving concussion symptoms or who return toplay too soon—while the brain is still healing—have a greater chance of getting anotherconcussion. A repeat concussion that occurs whilethe brain is still healing from the first injury canbe very serious and can affect a child or teen for alifetime. It can even be fatal.1. Remove your child or teen from play.2. Keep your child or teen out of play the day of the injury.Your child or teen should be seen by a health care providerand only return to play with permission from a health careprovider who is experienced in evaluating for concussion.3. Ask your child’s or teen’s health care provider for writteninstructions on helping your child or teen return to school.You can give the instructions to your child’s or teen’s schoolnurse and teacher(s) and return-to-play instructions to thecoach and/or athletic trainer.Do not try to judge the severity of the injury yourself. Only ahealth care provider should assess a child or teen for a possibleconcussion. Concussion signs and symptoms often show up soonafter the injury. But you may not know how serious the concussionis at first, and some symptoms may not show up for hours or days.The brain needs time to heal after a concussion. A child’s or teen’sreturn to school and sports should be a gradual process that iscarefully managed and monitored by a health care provider.To learn more, go towww.cdc.gov/HEADSUPYou can also download the CDC HEADS UPapp to get concussion information at yourfingertips. Just scan the QR code picturedat left with your smartphone.Revised 5/2015Discuss the risks of concussion and other serious brain injury with your child or teen and have each person sign below.Detach the section below and keep this information sheet to use at your children’s or teens’ games and practices to help protectthem from concussion or other serious brain injury.¡ I learned about concussion and talked with my parent or coach about what to do if I have a concussion or other seriousbrain injury.Athlete Name Printed: Date:Athlete Signature:¡ I have read this fact sheet for parents on concussion with my child or teen and talked about what to do if they have a concussionor other serious brain injury.Parent or Legal Guardian Name Printed: Date:Parent or Legal Guardian Signature:

State of Connecticut Department of EducationHealth Assessment RecordTo Parent or Guardian:In order to provide the best educational experience, school personnelmust understand your child’s health needs. This form requests informationfrom you (Part I) which will also be helpful to the health care provider whenhe or she completes the medical evaluation (Part II).State law requires complete primary immunizations and a health assessment by a legally qualified practitioner of medicine, an advanced practiceregistered nurse or registered nurse, licensed pursuant to chapter 378, a physi-cian assistant, licensed pursuant to chapter 370, a school medical advisor, ora legally qualified practitioner of medicine, an advanced practice registerednurse or a physician assistant stationed at any military base prior to schoolentrance in Connecticut (C.G.S. Secs. 10-204a and 10-206). An immunizationupdate and additional health assessments are required in the 6th or 7th gradeand in the 9th or 10th grade. Specific grade level will be determined by thelocal board of education. This form may also be used for health assessmentsrequired every year for students participating on sports teams.Please printStudent Name (Last, First, Middle)Birth Date Male FemaleParent/Guardian Name (Last, First, Middle)Home PhoneCell PhoneSchool/GradeRace/Ethnicity A merican Indian/Alaskan Native Hispanic/LatinoAddress (Street, Town and ZIP code)Primary Care Provider Black, not of Hispanic origin White, not of Hispanic origin Asian/Pacific Islander OtherHealth Insurance Company/Number* or Medicaid/Number*Does your child have health insurance?Does your child have dental insurance?YYNNIf your child does not have health insurance, call 1-877-CT-HUSKY* If applicablePart I — To be completed by parent/guardian.Please answer these health history questions about your child before the physical examination.Please circle Y if “yes” or N if “no.” Explain all “yes” answers in the space provided below.Any health concernsAllergies to food or bee stingsAllergies to medicationAny other allergiesAny daily medicationsAny problems with visionUses contacts or glassesAny problems hearingAny problems with speechYYYYYYYYYNNNNNNNNNHospitalization or Emergency Room visit YAny broken bones or dislocationsAny muscle or joint injuriesAny neck or back injuriesProblems running“Mono” (past 1 year)Has only 1 kidney or testicleExcessive weight gain/lossDental braces, caps, or bridgesFamily HistoryAny relative ever have a sudden unexplained death (less than 50 years old)Any immediate family members have high cholesterolYYYYYYYYNNNNNNNNNYYNNConcussionFainting or blacking outChest painHeart problemsHigh blood pressureBleeding more than expectedProblems breathing or coughingAny smokingAsthma treatment (past 3 years)Seizure treatment (past 2 years)DiabetesADHD/ADDPlease explain all “yes” answers here. For illnesses/injuries/etc., include the year and/or your child’s age at the time.Is there anything you want to discuss with the school nurse? Y NYYYYYYYYYYYYNNNNNNNNNNNNIf yes, explain:Please list any medications yourchild will need to take in school:All medications taken in school require a separate Medication Authorization Form signed by a health care provider and parent/guardian.I give permission for release and exchange of information on this formbetween the school nurse and health care provider for confidentialuse in meeting my child’s health and educational needs in school.HAR-3 REV. 4/2017Signature of Parent/GuardianDateTo be maintained in the student’s Cumulative School Health Record

Part II — Medical EvaluationHAR-3 REV. 4/2017Health Care Provider must complete and sign the medical evaluation and physical examinationStudent NameBirth edinPartIofthisform Date of ExamPhysical ExamNote: *Mandated Screening/Test to be completed by provider under Connecticut State Law*Height in. / %*Weight lbs. / %NormalBMI / % Pulse *Blood Pressure /Describe AbnormalOrthoNeurologicHEENT*Gross DentalLymphaticHeartLungsAbdomenGenitalia/ herniaSkin*Postural No spinalabnormality*Vision Screening*Auditory ScreeningRightLeftWith glasses20/20/Without glasses20/20/Type:Right Pass Fail No*IMMUNIZATIONS YesPPD date read: Spine abnormality: Mild Moderate Marked Referral madeHistory of Lead level 5µg/dL No YesLeft Pass FailDate*HCT/HGB:*Speech (school entry only) Referral made Referral madeTB: High-risk group?Describe sScreeningsType:NormalOther:Results:Treatment: Up to Date or Catch-up Schedule: MUST HAVE IMMUNIZATION RECORD ATTACHED*Chronic Disease Assessment:Asthma No Yes: Intermittent Mild Persistent Moderate Persistent Severe Persistent Exercise inducedIf yes, please provide a copy of the Asthma Action Plan to SchoolAnaphylaxis No Yes: Food Insects Latex Unknown sourceAllergiesIf yes, please provide a copy of the Emergency Allergy Plan to SchoolHistory of Anaphylaxis No YesEpi Pen required NoDiabetesSeizures No Yes: Type I No Yes, type: Type IIOther Chronic Disease: Yes This student has a developmental, emotional, behavioral or psychiatric condition that may affect his or her educational experience.Explain:Daily Medications (specify):This student may: participate fully in the school program participate in the school program with the following restriction/adaptation:This student may: participate fully in athletic activities and competitive sports participate in athletic activities and competitive sports with the following restriction/adaptation: Yes No Based on this comprehensive health history and physical examination, this student has maintained his/her level of wellness.Is this the student’s medical home? Yes No I would like to discuss information in this report with the school nurse.Signature of health care providerMD / DO / APRN / PADate SignedPrinted/Stamped Provider Name and Phone Number

Student Name:Birth Date:Immunization RecordHAR-3 REV. 4/2017To the Health Care Provider: Please complete and initial below.Vaccine (Month/Day/Year) Note: *Minimum requirements prior to school enrollment. At subsequent exams, note booster shots aHIBHep AHep BVaricellaPCVMeningococcalHPVFluOther*Dose 1*************Dose 2******Dose 3*Dose 4Dose 5Dose 6Required 7th-12th grade*Required K-12th gradeRequired K-12th gradeRequired K-12th gradeRequired K-12th gradePK and K (Students under age 5)***See below for specific grade requirement*Required PK-12th gradeRequired K-12th gradePK and K (Students under age 5)Required 7th-12th grade*PK students 24-59 months old – given annuallyDisease Hxof

Pre-Care 7:30-9:00 YMCA Post-Care 4:00-6:00 YMCA Drop-Off 9:00 Camp, 2705 Downes Rd Camp, 2705 Downes Rd 4:00 Camp, 2705 Downes Rd Bus 1 7:30 DD (State St./Ridge Rd.) Bus 1 5:20-5:25 DD (State St./Ridge Rd.) Bus 1 8:00 Hill House High Schoo