Student Health Form

Student Health Form

School:____________________________

Student   N ame:   L ast:    

 

 

 

 

 

  F irst:    

 

 

 

 

  G ender:    

 

Address:      

 

 

 

 

  C ity:    

 

 

 

  S tate:                   Z ip:      

 

 

 

Parent/Guardian:      

 

 

 

 

  C ell   P hone:    

 

 

 

 

 

 

 

Work   P lace:    

   

 

                A ddress:    

 

 

 

  C ity:    

 

 

State:    

              Z ip:      

 

Work   P hone:    

 

 

 

 

 

 

 

 

Student   D ate   o f   B irth:    

 

 

 

 

 

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  

Student   A ge_____   H eight_____   W eight_____   G rade_____  

legal   g uardian   i s   r equired   f or   p articipation   a t   A strocamp.  

 

DIETARY   N EEDS:  

MEDICAL   C ONSENT:   T he   s tudent’s   m edical   c onditions   s tated   o n   t his   a pplication   a re  

Vegetarian____   V egan____   L actose-­‐Intolerant____   G luten-­‐Free____   O ther____    

complete   a nd   c orrect.   I   h ereby   g ive   p ermission   t o   A STROCAMP   p ersonnel   t o  

 

administer   f irst   a id   a nd   t o   a rrange   f or   m edical   c are   a nd   t reatment   i n   c ase   o f   a  

FOOD   A LLERGIES:   P lease   D escribe:  

medical   e mergency.   I   a lso   g ive   p ermission   t o   t he   p hysician   s elected   b y   A STROCAMP  

 

personnel   t o   e xamine,   d iagnose,   a nd   t reat   o r   s ecure   p roper   t reatment   f or   t he   s tudent  

 

as   t he   p hysician   s hall   d etermine   w hat   i s   p roper   a nd   n ecessary   u nder   t he  

 

circumstances.   A   p hotocopy   o f   t his   a uthorization   s hall   b e   a s   v alid   a nd   m ay   b e  

 

accepted   a s   t he   o riginal.  

 

 

CHECK   O FF:   A ll   a pplicable   h ealth   i ssues:  

PARENTAL   A UTHORIZATION:   I   h ave   b een   i nformed   o f   t he   n ature   o f   t he  

___   A llergies*  

 

___   A llergy   –   B ee   S ting*  

ASTROCAMP   p rogram   i n   w hich   t he   s tudent   i s   e nrolled.   I   u nderstand   t hat   t here   a re  

___   A sthma  

 

___   B ackaches/Weak   B ack  

risks   a ssociated   w ith   t he   s tudent’s   p articipation   i n   t he   p rogram   a ctivities   a nd  

___   C ar/Sea   S ick  

 

___   B owel/Bladder   P roblems  

transportation   t o   a nd   f rom   t he   c amp,   w hich   c an   p ose   a   t hreat   o f   i njury,   i llness,   o r  

___   D iabetes  

 

___   E pilepsy/Convulsive   D isorder    

death.     T he   u ndersigned   i s   f amiliar   w ith   o utdoor   s ports   a nd   a ctivities   a nd   t he  

___   H ay   F ever  

 

___   H eadache  

student’s   a bilities   a nd   I   a m   n ot   a ware   o f   a ny   p hysical,   e motional,   o r   m ental   p roblem  

___   H eart   T rouble  

 

___   P oison   O ak  

or   l imitation   t hat   w ould   p revent,   i mpair,   o r   i ncrease   t he   r isks   i nvolved   i n   t he  

___   S inus   I ssues  

 

___   R espiratory   P roblems**  

student’s   p articipation   i n   A STROCAMP   a ctivities.  

___   S leep   W alking  

 

___   V omiting  

          W ith   t his   k nowledge,   I   g rant   p ermission   f or   t he   s tudent   t o   p articipate   i n   a ll   c amp  

 

activities   a nd   o n   b ehalf   o f   t he   u ndersigned   a nd   t he   s tudent,   I   a ccept   a nd   a ssume   t he  

*     H as   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  

risk   a nd   f ull   r esponsibility   f or   i njury,   i llness,   d eath,   o r   l oss   o f   p ersonal   p roperty   o r  

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.  

**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  

other   d amage,   a nd   m edical   o r   o ther   e xpense   r esulting   f rom   t he   s tudent’s   p resence   a t  

activities?   Y ES   _ ___   N O____.   I f   Y ES,   t he   i nhaler(s)   m ust   a ccompany   y our   c hild   t o  

ASTROCAMP.  

 

camp   i n   o rder   t o   p articipate   i n   a ctivities.

          I   h ereby   r elease   a nd   d ischarge   G uided   D iscoveries,   I nc.,   A STROCAMP,   a nd   t heir  

 

agents   a nd   e mployees   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 osses,  

Please   s pecify   w ith   Y ES   o r   N O   f or   e ach   m edication   t hat   c an   b e  

damages,   a nd   e xpenses   a nd   a ny   i njury   t o   p erson   o r   p roperty,   i ncluding   d eath,  

administered   t o   y our   c hild.  

resulting   f rom   t he   s tudent’s   t ravel   t o   o r   f rom   A STROCAMP   a nd   p articipation   i n   t he  

__________   P epto   B ismol   ( upset   s tomach)  

program.  

__________   M ilk   o f   M agnesia   ( for   c onstipation)  

          I   a gree   t o   d irect   t he   s tudent   t o   c omply   w ith   a ll   A STROCAMP   r ules   a nd   p olicies,  

__________   I buprofen   ( minor   a ches   p ains;   f ever)  

and   t o   c ooperate   w ith   A STROCAMP   p ersonnel.   I   u nderstand   a nd   a gree   t hat   i f   t he  

__________   T hroat   L ozenge/Cough   D rop  

student   f ails   t o   c omply   w ith   t he   r ules   a nd   p olicies,   h e   o r   s he   m ay   b e   e xpelled   f rom  

__________   B enadryl  

ASTROCAMP   a nd   s ent   h ome   a t   m y,   t he   p arent   o r   l egal   g uardian’s,   e xpense.  

__________   C aladryl   ( for   s kin   r ash)  

          I   g ive   p ermission   a nd   c onsent   f or   m y   c hild   t o   a llow   p hotographs   a nd   v ideo   t o   b e  

__________   A ceteminophen   ( headaches/elevated   t emperatures)  

taken   d uring   A STROCAMP   s chool-­‐year   p rograms.   I   f urther   g ive   p ermission   a nd  

 

consent   t hat   a ny   s uch   p hotographs   a nd   v ideo   m ay   b e   p ublished   a nd   u sed   b y   G uided  

Is   t he   s tudent   r equired   t o   t ake   r egular   m edication?  

Discoveries   t o   i llustrate   a nd   p romote   i ts   c amp   a nd   s chool-­‐year   p rograms   i n   a ny   a nd  

 

all   m edia   n ow   o r   h ereafter   k nown,   f or   i llustration,   p romotion,   a rt,   a nd   a dvertising.  

YES    

 

NO    

 

 

 

SIGNATURE

:    

 

 

 

 

 

 

All   m edications   a re   a dministered   b y   t he   c haperones    

 

 

 

Parent/Legal   G uardian  

from   t he   s tudent’s   s chool.   P lease   p rovide   i nstructions    

 

(dose)   f or   a dministration   o f   m edication.  

Please   P rint   N ame:      

 

 

      D ate:   _ _____________________  

 

 

What   i mportant   m edical   n eeds   s hould   A STROCAMP   b e   a ware   o f?  

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  

Please   e xplain   i n   d etail   ( Attach   a dditional   s heet   i f   n ecessary).  

everyone   w ithout   r egard   t o   r ace,   c olor,   n ational   o rigin,   s ex,   o r   h andicap.  

 

 

 

 

 

                    R eturn   t o   S chool