Student Health Form

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STUDENT HEALTH FORM
School:__________
Cherry Cove
Fox Landing
Toyon Bay
Student   N ame:   L ast:  
  F irst:  
  G ender:  
Address:      
  C ity:  
  S tate:  
              Z ip:  
Parent/Guardian:      
  C ell   P hone:  
Work   P hone:  
Work   P lace:    
                A ddress:  
  C ity:    
State:  
              Z ip:  
Height    
Weight  
  S tudent   A ge:  
    S tudent   D ate   o f   B irth:  
k  
Emergency   C ontact:    
Health   I nsurance   C o:  
Address:    
Policy   N o:    
City:    
 
  S tate:  
Phone:      
Phone:      
Family   P hysician:    
Phone:  
Relationship   t o   S tudent:  
Date   o f   L ast   T etanus:    
IMPORTANT:   A   s ignature   a t   t he   b ottom   o f   t his   f orm   b y   a   p arent   o r  
DIETARY   N EEDS:  
Vegetarian____   V egan____   L actose-­‐Intolerant____   G luten-­‐Free____   O ther____    
legal   g uardian   i s   r equired   f or   p articipation   a t   C IMI.  
FOOD   A LLERGIES:   P lease   D escribe:  
EMERGENCY   M EDICAL   C ONSENT:   T he   S tudent’s   m edical   c onditions   a nd  
information   s tated   o n   t his   a pplication   i s   c omplete   a nd   c orrect.   I   g ive   p ermission   t o  
the   C IMI   c amp   s taff   a nd   S chool   c haperones   t o,   ( 1)   a dminister   t he   S tudent’s   r outine  
medications   l isted   i n   t his   A pplication,   a s   w ell   a s   n eeded   m edications   a nd   o ver-­‐the-­‐
counter   m edications   f or   m inor   i llness   o r   d iscomfort;   ( 2)   i n   c ase   o f   a   m edical  
CHECK   O FF:   A ll   a pplicable   h ealth   i ssues:  
emergency   t o   p rovide   a ppropriate   fi rst   a id   f or   m inor   i njuries;   a nd   ( 3)   s eek   f urther  
treatment   f rom   l ocal   p hysicians   o r   h ospitals   i f   t he   m edical   c ondition   w arrants.   I n   t he  
___   A llergies*  
___   A llergy   –   B ee   S ting*  
event   I   c annot   b e   r eached   i n   a n   e mergency,   I   a lso   g ive   p ermission   t o   t he   p hysician  
___   A sthma  
___   B ackaches/Weak   B ack  
selected   b y   C IMI   o r   t he   S chool   c haperone   t o   e xamine,   d iagnose,   a nd   t reat   o r   s ecure  
___   C ar/Sea   S ick  
___   B owel/Bladder   P roblems  
proper   t reatment   f or   t he   S tudent   a nd   h ospitalize,   a nd   t o   o rder   i njection   a nd/or  
___   D iabetes  
___   E pilepsy/Convulsive   D isorder    
anesthesia   a nd/or   s urgery   f or   t he   S tudent,   a s   t he   p hysician   s hall   d etermine   p roper  
___   H ay   F ever  
___   H eadache  
and   n ecessary   u nder   t he   c ircumstances.   A   p hotocopy   o f   t his   A uthorization   s hall   b e   a s  
___   H eart   T rouble  
___   P oison   O ak  
valid   a nd   m ay   b e   a ccepted   a s   t he   o riginal.   T his   c ompleted   A pplication   m ay   b e  
___   S inus   I ssues  
___   R espiratory   P roblems**  
photocopied   b y   C IMI   a nd   r eleased   t o   t he   p hysicians   o r   h ospitals   i f   r equested.     T his  
___   S leep   W alking  
___   V omiting  
Consent   i s   g iven   p ursuant   t o   t he   p rovisions   o f   C alifornia   F amily   C ode   § 6910.  
*Has   y our   c hild   b een   p rescribed   a n   E piPen   f or   a llergies?   Y ES____NO___.   I f   Y ES,   t he
CONSENT   A ND   R ELEASE   O F   L IABILITY:   I   h ave   b een   i nformed   o f   t he   n ature   o f   t he  
EpiPen   m ust   a ccompany   y our   c hild   t o   c amp   i n   o rder   t o   p articipate   i n   a ctivities.  
CIMI   p rogram   i n   w hich   t he   S tudent   i s   e nrolling.     I   u nderstand   t hat   t here   a re   r isks  
associated   w ith   t he   S tudent’s   p articipation   i n   c amp   p rograms   a nd   a ctivities   a nd  
**Does   y our   c hild   r equire   a n   i nhaler(s)   o n   a   d aily   b asis   a nd/or   f or   e xercise-­‐induced  
activities?   Y ES   _ ___   N O____.   I f   Y ES,   t he   i nhaler(s)   m ust   a ccompany   y our   c hild   t o  
transportation   t o   a nd   f rom   c amp,   w hich   c an   p ose   a   t hreat   o f   i njury   o r   i llness.   I   a m  
 
camp   i n   o rder   t o   p articipate   i n   a ctivities.
familiar   w ith   o utdoor   s ports   a nd   a ctivities   a nd   t he   S tudent’s   a bilities   a nd   I   a m   n ot  
aware   o f   a ny   p hysical,   e motional,   o r   m ental   p roblem   o r   l imitation   t hat   w ould  
Please   s pecify   w ith   Y ES   o r   N O   f or   e ach   m edication   t hat   c an   b e  
prevent,   i mpair,   o r   i ncrease   t he   r isk   o f   h arm   i nvolved   i n   t he   S tudent’s   p articipation  
administered   t o   y our   c hild.  
in   C IMI   c amp   a ctivities.   I   a lso   r ecognize   t hat   C IMI   c annot   e nsure   o r   g uarantee   t hat  
__________   P epto   B ismol   ( upset   s tomach)  
the   p articipants,   e quipment,   g rounds   a nd/or   a ctivities   w ill   b e   f ree   o f   a ccidents   o r  
__________   M ilk   o f   M agnesia   ( for   c onstipation)  
injuries.   I   a m   a ware   a nd   h ave   o r   w ill   i nstruct   t he   S tudent   i n   t he   i mportance   o f  
__________   I buprofen   ( minor   a ches   p ains;   f ever)  
knowing   a nd   a biding   b y   t he   C IMI   c amp   r ules   a nd   r egulations.   I   a gree   t o   d irect   t he  
__________   T hroat   L ozenge/Cough   D rop  
Student   t o   c omply   w ith   a ll   C IMI   r ules   a nd   p olicies,   a nd   t o   c ooperate   w ith   C IMI  
__________   B enadryl   ( allergy)  
personnel.   I   u nderstand   a nd   a gree   t hat   i f   t he   S tudent   f ails   t o   c omply   w ith   C IMI   r ules  
__________   C aladryl   ( for   s kin   r ash)  
or   p olicies,   h e   o r   s he   m ay   b e   e xpelled   f rom   c amp   a nd   s ent   h ome   a t   m y,   t he   p arent   o r  
__________   A ceteminophen   ( headaches/elevated   t emperatures)  
legal   g uardian’s,   e xpense.    
__________   B onine/Meclazine/Dramamine   ( motion   s ickness)  
          W ith   t his   k nowledge   a nd   u nderstanding,   I   g rant   p ermission   f or   t he   S tudent   t o  
participate   i n   a ll   C IMI   c amp   a ctivities   a nd   o n   b ehalf   o f   t he   u ndersigned   a nd   t he  
Student,   I   a ccept   a nd   a ssume   t he   r isk   a nd   f ull   r esponsibility   f or   i njury   a nd   i llness   o r  
Is   t he   s tudent   r equired   t o   t ake   r egular   m edication?  
loss   o f   p ersonal   p roperty   o r   o ther   d amage,   a nd   m edical   o r   o ther   e xpense   t hat   m ay  
result   f rom   t he   S tudent’s   p resence   o r   p articipation   i n   t he   a ctivities   a t   C IMI   c amp.    
YES    
NO    
          I   h ereby   r elease   a nd   d ischarge   G uided   D iscoveries,   I nc.,   C IMI,   a nd   t heir   a gents   a nd  
employees   f rom   l iability   t o   u s   a nd   t o   t he   S tudent   f or   a ny   a nd   a ll   l oss,   d amage,   a nd  
All   m edications   a re   a dministered   b y   t he   c haperones    
expense   a nd   a ny   i llness   o r   i njury   t o   p erson   o r   p roperty,   r esulting   f rom   t he   S tudent’s  
from   t he   s tudent’s   s chool.   P lease   p rovide   i nstructions    
travel   t o   o r   f rom   C IMI   a nd   p articipation   i n   t he   c amp   a ctivities   a nd   p rograms.  
(dose)   f or   a dministration   o f   m edication.  
          I   g ive   p ermission   f or   C IMI   t o   u se   a ny   p hotographs,   v ideo,   o r   i nterview   t aken   a t  
camp   t o   b e   u sed   t o   i llustrate,   r eport,   p romote   o r   a dvertise   C IMI   o r   G uided  
WHAT   I MPORTANT   M EDICAL   N EEDS   S HOULD   C IMI   B E   A WARE   O F?  
Discoveries   p rograms   o r   c amps.  
PLEASE   E XPLAIN   I N   D ETAIL.    
SIGNATURE:    
(Attach   a dditional   s heet   i f   n ecessary.)  
Parent/Legal   G uardian  
Please   P rint   N ame:    
      D ate:   _ _____________________  
Rules   f or   a cceptance   a nd   p articipation   i n   G uided   D iscoveries,   I nc.   p rograms   a re   t he   s ame   f or  
everyone   w ithout   r egard   t o   r ace,   c olor,   n ational   o rigin,   s ex,   o r   h andicap.  
 

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