UCUCC YOUTH PROGRAM HEALTH FORM
A completed and signed health form must be on file for all youth program participants. This form is to be completed by the parent/guardian. Please notify Margaret Irribarra if any of this information should change or need to be updated. Youth’s Name
Gender: F / M / Gender Neutral / Transgender Birth date____________ Height_____ Weight
Parent’s/Guardian’s name/s:__________________________________________________________ Work phone________________ Cell phone_______________ Home Phone______________ In case of emergency, notify
Cell Phone (_______)_____________________________ Insurance and Physician Information Participant’s insurance company Swimming Ability:
o doesn’t know how to swim o poor o fair o good o excellent
Immunizations (Please give month/year) Tetanus ___ / ___ Polio ___ / ___ DPT ___ / ___ MMR ___ / ___
Meningitis ___/___ Hepatitis B ___/____
Allergies (Please check yes or no) Hay fever o Yes o No
please explain reaction: _____________________________________________________________________________________________ Dietary information: Vegetarian o Yes o No
Any special diet instructions? _________________________________________________________________________ Any food allergies? ________________________________________________________________________________ Has the youth experienced any major life event that might impact his/her experience in youth group or on retreats? IF YES, PLEASE EXPLAIN (you can use another sheet of paper if needed): _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ Health Concerns (Please check yes or no)
o Yes o No Ear, nose, throat o Yes o No Anxiety
- continues on p.2
Name of Participant: _______________________________________ Please explain any of the above “Yes” responses or any other physical or emotional challenges
Is the participant in general good health and able to participate in all normal activities? o Yes o No Please explain any restrictions
Special needs: ADA room_______; large print_______; signing_______; hearing device_______; Current Medications MEDICATION DOSAGE SCHEDULE REASON ________________________________ __________________ _______________________ _______________________________
________________________________ __________________ _______________________ _______________________________
________________________________ __________________ _______________________ _______________________________
________________________________ __________________ _______________________ _______________________________
Can your youth be expected to take the right amount of medication at the proper time? Yes No ► If you give your youth permission to administer his/her own medication, please sign here: __________________________ ____________________________ print name sign name (If the answer is no, permission to administer must be given to the youth minister/s traveling with your youth.) Please send medications in their original containers. Send only the amount needed, plus 2 extra doses. Do not send a huge supply. Consent and Emergency Treatment Authorization: I request and authorize the area hospitals, medical staff personnel, agents and employees, to have access to information contained in this form and to provide all medical care, routine tests and necessary transportation advisable for my health or the health of my child. I acknowledge that no representations, warranties or guarantees as to result or cures will be made. I hereby give permission to medical staff to secure and administer treatment including hospitalization
for myself ______________________________________(adult advisors) or for my child, __________________________________________________ (youth participants). Signature of Parent/Guardian
Please note: Over-the-counter or internally-administered medication of any kind including Ibuprofen (Motrin/Advil) and Tylenol (acetaminophen) will not be administered to minors in attendance at the events without express permission of the parent/ guardian or attending physician. Use the attached Over-the-Counter Medication form to give permission. - continues on p.3 Over-the-Counter Medications
To treat symptoms that your youth might have while on the retreats or other youth events, we ask that you fill
out the following table of over-the-counter medications which will be administered to your youth if he/she can
take them. These are for the occasional need and will be given only with parental permission below. We will stock a moderate supply of the items listed below . Important: All prescription medication must be sent in its original container. Symptom Medication Yes No Comments
Antihistamine for mild al ergic reactions
List any other Over-the-Counter medicine that you do NOT want administered to your youth?
____________________________________________________________________________
Youth’s Name _______________________________________________ (PRINT CLEARLY, thanks) Parent’s/Guardian’s Signature ___________________________________________ Date__________________________ If you need more room for comments, please use the backside of this sheet.
Meaning of p-value in Medical Research Corresponding Author: Dr. Brijesh Sathian, Assistant Professor & Managing and Chief Editor NJE, Community Medicine, Manipal College of Medical Sciences, Department of Community Medicine, Manipal College of Medical Sciences, 155 - Nepal Submitting Author: Dr. Brijesh Sathian, Assistant Professor & Managing and Chief Editor NJE, Community