Microsoft word - 2013-14 medical form-3.doc

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.

Source: http://www.universityucc.org/education/medicalrelease.pdf