REGIONAL YMCA OF WESTERN CT

GREAT HOLLOW WILDERNESS SCHOOL

225 Route 37

New Fairfield, CT 06812

Phone: (203)746-5852 Fax: (203)746-1232

Medical Form: Courses 1-3 

Name: ____________________________________________ ^{Last First Middle} Home Address: _____________________________________ ^{Number Street Apt Number} __________________________________________________ ^{City State Zip Code}

^{E-mail Address(s)}: __________________________________________________________________________________

Home Telephone: ( ____________________) Birthdate: ________________________ ^{Area Code Number Month Date Year}
Gender:  Female  Male Name of Physician: ____________
Physician’s Address _____________________________________________________________ Physician’s Phone _______________________________________________________________
NAME OF INSURANCE COMPANY ISSUING MEDICAL CARE AND HOSPITALIZATION COVERAGE:
____Policy/Certificate # ____________________________________
_____________________________________________________________________________________________________________________________ ^{Street City State Zip Code}
Home:__________________________Office:__________________________Cell:_______________

List and describe any illness, any condition for which you are now under treatment, any disability, any medications you are currently taking, any medicines to which you are allergic, and any other allergies (insect bites, etc.).

 

X ^{Signature (of Parent or Guardian if applicant under age 18) Date}