Child Medical Consent Form printable pdf download

Child’s Full Name:

Date Attending: June 23 & 24, 2016

Name of Event

University

Last

First

Grandparents University® Winona State

Full Home Address:

Home Telephone Number:

Date of Birth: ____/____/_____

Sex:

M F

Height:

Weight:

Parent/Guardian Name:

Relationship:

Does your child have allergic reactions to:

□ Yes □ No ................ Medications (list) ___________________

Address (if different than above)

Home Telephone Number:(if different than above)

□ Yes □ No ................ Insect Bites/Stings/Animal dander, etc

Parent/Guardian Work Telephone:

_________________________________

□ Yes □ No ................ Food (list) _______________________

Alternate contact in the event that the Parent/Guardian cannot be contacted during an injury or illness (Name,

Does your child take medication on a regular basis?

Relationship, Address, and Telephone Number). Please note if this contact is the adult accompanying your child

□ Yes □ No If Yes, Identify ______________________

to Grandparents University®.

(Consent for medication administration must be signed on

reverse.)

Has your child ever had or is your child presently experiencing:

□ Yes □ No Asthma

□ Yes □ No Bleeding Disorder

Physician: ____________________________________ Telephone:___________________

□ Yes □ No Cancer

Insurance Co.: _________________________________ Policy No.: ______________

□ Yes □ No Colitis

□ Yes □ No Diabetes

□ Yes □ No Eating Disorder

Immunization Record –Please check all immunizations child has had.

□ MMR (measles, mumps, rubella)

□ Hepatitis A

□ Yes □ No Emotional Difficulties

□ Tetanus-Diphtheria (DTaP)

□ Hepatitis B

□ Yes □ No Epilepsy/Seizures/Blackouts

□ Yes □ No Female Difficulties

□ IPV (polio)

□Varicella (Chicken Pox)

□ Yes □ No Frequent Headaches

□ Influenza

□ HiB (Meningitis)

□ Yes □ No Hay Fever

* Year of last tetanus boost (must be within last 10 years)

□ Pneumococcal conjugate vaccine (PCV)

□ Yes □ No Heart Disease or murmur

Has participant ever had major surgery or been hospitalized?

□ Yes □ No

□ Yes □ No High Blood Pressure

Please explain any significant operations, injuries, illnesses, or infectious diseases and last medical attention and

reason:

□ Yes □ No Hernia

□ Yes □ No Joint Injury/Surgery

□ Yes □ No Kidney Disease

□ Yes □ No Mononucleosis in past 12 months

□ Yes □ No Neck/Back Pain/Injury

□ Yes □ No Rheumatic Fever

□ Yes □ No Sleepwalking

□ Yes □ No Tuberculosis

□ Yes □ No Ulcer

Does the participant have any physical condition(s) requiring special considerations or restrictions to activity?

Explain. _________________________________________________________________

□ Yes □ No Use of orthodontic appliances

A physical examination within 36 months of Grandparents University

is required.

□ Yes □ No Wear glasses/contacts

Date of participant's last physical examination:

Other: ____________________________________________

S:\Retiree_Center_office\Grandparent University\Grandparent University Forms\Form - Child Medical Consent.docx

Child Medical Consent Form

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