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.