Women’s Weekend Health Form

Step 1 of 2

Women's Weekend Health History/Covid Form
This information is vital for your own Health and Safety during the weekend. This online form now replaces the standard Health and Release Form that was brought with you. You do not need to bring a copy with you for the weekend.
Participant Name*
First Last
Email
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Emergency Contact Information
Primary Emergency Contact Name*
First Last
Relationship
Primary Emergency Contact Phone*
Primary Emergency Contact Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Health History
Allergies. Please describe reaction and management of the reaction.
Dietary Restrictions*
- None
- Vegetarian
- Vegan
- No Gluten
- No Dairy
- Other
Have you been fully vaccinated for COVID-19?*
If YES, please upload your certificate of COVID-19 vaccination.
Max. file size: 50 MB.
If NO, please upload your PCR COVID-19 test result. You must show proof of a negative COVID-19 result from a test that was taken within 72 hours of your arrival.
Max. file size: 50 MB.
I understand that since I am not vaccinated, I agree to not leaving the premises of Camp Takodah. If I do leave, I realize I will be unable to return.*
Authorization: I attest that the above health information provided is accurate and complete. I hereby grant permission to qualified instructors or other medical personal to secure and administer treatment, including hospitalization, for me in an emergency. This completed form may be photocopied for use on trips out of camp.*

Women's Weekend Statement of Risk and Release
Please read carefully before accepting and agree to each statement.
Photo/Media Release: I authorize the reproduction, publication and use by the Takodah YMCA for promotional, marketing, public relations, or any other purpose, any pictures or likeness of me taken during the YMCA Camp Takodah Programs.*
I, the undersigned, am aware that the Camp Takodah Outdoor Programs are designed to be challenging-physically, mentally, and emotionally. I understand that the Camp Takodah Outdoor Programs involve land and water-based activities in an outdoor setting.*
I understand that certain risks and dangers are inherent and exist within the rigorous physical activities in which, I, the undersigned, will be participating in throughout the experience.*
I acknowledge that while the program and its staff has carefully designed the activities and makes every reasonable effort to reduce all dangers, hazards, and perils associated with these activities, the risk of injury or disability cannot be totally eliminated.*
I understand this form and my Health/Medical Information Form must be completed and returned to Camp Takodah prior to participation in any activities. I, the undersigned, am not under a physician's care for any undisclosed condition that bears upon my fitness to participate in Camp Takodah Outdoor Programs.*
I understand my personal duty and responsibility to learn and follow the safety standards, guidelines, and procedures established by the instructors. I will make the instructors aware at any point during the activity in which I question my knowledge of these standards, guidelines, and procedures, or my ability to participate.*
Electronic Signature*
By my electronic signature below, I hereby warrant that I: (1) have read the above statements and understand the risks associated with participation in Camp Takodah Outdoor Programs, and (2) am aware of and have met all of the prerequisites to participation in this program. This includes having completed and returned the Health/Medical Information Form and assuming risk/accident insurance coverage, and (3) give consent to the instructors or other medical personnel to treat me in an emergency situation.
First Last
Date*
MM slash DD slash YYYY
Thank you so much and we can't wait for you to join us this Fall for another great Women's Weekend.

Women’s Weekend Health Form

Step 1 of 2

Women's Weekend Health History/Covid Form

Emergency Contact Information

Health History

Women's Weekend Statement of Risk and Release

Thank you so much and we can't wait for you to join us this Fall for another great Women's Weekend.