McGaw YMCA Camp Echo | Session 6 (2023) - (All Camp)

Condon, Kathryn (Katy) (C), Oct 26, 2014 (8.06) Printed May 1, 2023 Updated May 1, 2023

LEGAL GUARDIANS
Matt Condon (Father) C:8158148657 Rebecca Condon (Mother) C:773-273-1746

Address 9741 Karlov Ave, Skokie, IL, 60076 Home Phone 7732731746

EMERGENCY CONTACTS
Mary Mahady (grandma) Sue Condon (grandma)
773-273-1746 815-455-1524

MEDICAL PROFESSIONALS
Doctor Dr. Elizabeth Swider - Northshore - 847-570-1507 MentalHealth Not Supplied

PERMISSION TO CONTACT PROVIDER COMMENTS

Yes

INSURANCE
Policy Holder's Name Matt Condon Policy Holder's Birth Date 11/8/1981
SSN or Insurance ID XOF8272269585 Policy Holder's Relationship Father
Insurance Carrier BlueCross BlueShield Policy Number XOF8272269585
Carrier Phone # 1-800-541-2763 Group Number P84133
Claims processing address Rx Bin Number 011552
BCBSIL, P.O. Box 805107,
Chicago, IL 60680-4112 Kathryn Condon is not covered by a prescription plan.

Diseases Test Date Results Immunizations Dose 1 Dose 2 Dose 3 Dose 4 Dose 5 Latest
Tuberculosis N/A N/A COVID 19 -
Pfizer
COVID 19 -
Last Occurrence
Moderna
COVID-19 05/30/2022
Very little symptoms COVID 19 -
Johnson &
Chicken Pox Never
Johnson
German Never COVID 19 -
Measles
AstraZeneca
Hepatitis A Never
Never COVID 19 -
Hepatitis B
Novavax
Hepatitis C Never
COVID 19 -
Measles Never
Sinopharm/BIBP
Mumps Never
DTaP or TDaP
H1N1 Never
Tetanus,
Pertussis
booster
MMR
IPV
HIB
PCV
Hepatitis B
Hepatitis A
Chicken Pox
MCV4
H1N1
Flu
I attest that all {FirstName}'s immunizations required
for school are up to date.

PHYSICAL HEALTH HISTORY

Abnormal Menstrual History
Diarrhea, Constipation
HIV
Lice
Skin Problems (itching, rash)
Anorexia, Bulimia Back Problems Bleeding, Clotting
Chest Pain, Dizzy, Passing Out Glasses, Contacts, or Protective Heart Murmur
Eyewear High Blood Pressure
Immunodeficiency Joint Problems (ankles, knees) Knocked Unconscious
Mono (in the last 12 months) Orthodontic Appliance Required at Seizures, Convulsions
Camp Short of Breath, Wheezing
Other Issue Head Concussion in Past Year

PHYSICAL HEALTH HISTORY DETAILS

Issue Date Notes

 McGaw YMCA Camp Echo | Session 6 (2023) - (All Camp)
Condon, Kathryn (Katy) (C), Oct 26, 2014 (8.06) Printed May 1, 2023 Updated May 1, 2023

LEGAL GUARDIANS
Matt Condon (Father) C:8158148657 Rebecca Condon (Mother) C:773-273-1746

Address 9741 Karlov Ave, Skokie, IL, 60076 Home Phone 7732731746

Heart Murmur Ongoing She has had this since she was born and has never had an issue with this.
Skin Problems (itching, rash) Ongoing She has sensitive skin - can get red or itchy but nothing serious

ALLERGIES

Type Allergen Anaphylactic Reaction Last Reaction Comments

She gets stuffy nose, red eyes. She takes Claritin or
Environmental Pollen No 04/DD/2023
Zertex.

ASTHMA
This person does not have asthma.

DIABETES

This person does not have diabetes.

RECURRING HEALTH ISSUES

There are no recurring health issues listed for this person.

OPERATIONS AND SERIOUS INJURIES

This person has not had any operations or serious injuries.

OTHER ISSUES

There are no other health issues listed for this person.

TRAVEL OUTSIDE OF THE UNITED STATES

This person has not traveled outside of the United States in the past 9 months.

MENTAL HEALTH
Attention Deficit Disorder (ADD or Depression Disordered Eating Learning or Processing Challenge
AD/HD) (disability)
Obsessive-Compulsive Disorder Panic, Anxiety Disorder Substance Abuse Other Mental, Emotional, or Social
Health Issue

NUTRITION
No Dairy No Eggs No Fish No Pork No Poultry No Red Meat No Seafood No Wheat Vegan
Vegetarian

PRESCRIPTIONS

Name Dramamine Dosage 2 tablets Initial Count 8 StartDate 8/11/2023 EndDate 8/11/2023
Status Pending
Delivery Method As Needed
Reason This should be taken before coming home on the bus for car sickness.
Memo Take an hour before leaving.

TERMS & CONDITIONS

[h]REQUIRED AUTHORIZATIONS: SIGNED BY PARENT. PLEASE READ AUTHORIZATIONS BEFORE SIGNING [/h]

All information is correct and the participant has permission to engage in all camp activities except as noted on this
form. I understand that failure to complete all portions of this form could result in an injury or compound the danger of
an injury.

I hereby give permission to treat and I understand that I am financially responsible for medical bills and pharmacy
charges.

*If you do not wish to give permission to treat, please contact the Echo staff at echoinfo@mcgawymca.org to complete the
"Do Not Treat Waiver."

The information on this form is correct so far as I know, and the participant has my permission to engage in all camp
activities that are part of the program they are enrolled in, as described in the brochure, parent packet, and website,
on or off camp property, except as noted on the back of this form. I understand that failure to complete all portions of
this form could result in an injury or compound the danger of an injury

I hereby give permission to the Camp Echo Health Officers, acting on behalf of the McGaw YMCA Camp Echo, to provide
 McGaw YMCA Camp Echo | Session 6 (2023) - (All Camp)
Condon, Kathryn (Katy) (C), Oct 26, 2014 (8.06) Printed May 1, 2023 Updated May 1, 2023

LEGAL GUARDIANS
Matt Condon (Father) C:8158148657 Rebecca Condon (Mother) C:773-273-1746

Address 9741 Karlov Ave, Skokie, IL, 60076 Home Phone 7732731746

routine non-surgical health care; to administer prescription medications I've supplied, as well as over-the-counter
medications* appropriate for the situation; and to transport the participant to the next level of medical care if
required. In the event I cannot be reached in an emergency, I hereby give permission to the licensed health care
provider selected by the Camp Director to secure and administer treatment, order x-rays, order routine tests,
hospitalize, and order injection, anesthesia or surgery for the participant. This completed form may be photocopied for
trips out of camp. I understand that I am financially responsible for medical bills due to office/ER visits and/or
pharmacy charges.

By my signature I affirm that this health history is correct and complete to the best of my knowledge and that I have
read, understood and agree to the Terms and Conditions specified in this form.

Signature Rebecca Condon Date 5/1/2023 11:48:12 AM