YLC 2019 Leader Health Form

  • To be completed by camper’s doctor/physician by June 16, 2019. If you need a printable form, please email [email protected] to receive PDF copy of this form. Physical exams made before August 11, 2018 will not be accepted.
  • Camper's Full Name * Required
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Please check if the camper has had any of the following health problems. If you checked yes, please explain the comment box provided below.
  • NoYes
    Allergies (Food, Drugs, Plants, Insects, etc.)
    Asthma (If yes, does he/she use an inhaler?)
    Back/Joint Pains
    Cardiovascular Disorders
    Cerebral Palsy
    Chicken Pox
    Clotting Disorders
    Diabetes
    Epilepsy/Convulsions
    Eye Infections
    Fainting
    Frequent Ear Infections
    German Measles
    Hemophilia
    Hernia
    Measles
    Meningitis
    Menstrual Problems
    Mumps
    Nose Bleeds
    Respiratory Infections
    Rheumatic Fever
    Severe Vision Problem
    Stomach/Intestinal Problems
    Urinary Tract Infections
    Vaginal Infections
    Mental Health Concerns (including ADHD, Depression, etc.)
    Major Surgeries
    Serious Injuries
    Physical Limitations
  • Date Format: MM slash DD slash YYYY
  • I certify that I have on this date examined the above named camper and that on the basis of my examination and on the medical history as furnished to me, I have found no reason that would make it medically inadvisable for this staff member to participate in physically strenuous activities.
  • Licensed Physician's Name
  • Address
  • If you have any questions about this form, please email [email protected] with subject header: “YLC Camper Completed Health Form”.