Student Medical Form printable pdf download

Maritime Programs Curriculum Series

STUDENT MEDICAL FORM

PLEASE PRINT CLEARLY

I/We, the parent(s) or guardian(s) of the participant named below, wish to register my/our child in the Maritime Museum of

San Diego Overnight Program. Dates attending _______________ to _______________.

Participant’s Name (Last)_________________________

(First) __________________________

Home Phone (____) _____________________

Birth date ____ / ____ / ____

Address ___________________________________ City _____________________ State _____ Zip _________

In case of emergency, please notify: Parent(s)/Guardian(s)

Name_____________________________________________

Address ___________________________________City _____________________ State _____ Zip _________

Daytime Phone Number (____) __________________

*Business Number (____) __________________

*Employer ___________________________________

Alternate Person in case of emergency, please notify: _____________________ at (____) __________________

Name/Phone number of Family Physician_________________________________________________________

Name/Number of family medical insurance carrier__________________________________________________

* For Medical Insurance Claims only

PARTICIPANT HEALTH INFORMATION

1. Does the participant have any physical or medical conditions or restrictions? Yes ____ No ____ Vegetarian ____

If so, please describe:_________________________________________________________________________

If your child has a special medical or physical condition, your physician should understand that the participant will

be away from home for two full days. Please have your physician write a note indicating agreement that the

participant is fit enough to fully participate in the program and to also include any special instructions.

Is your child subject to any of the following? Please circle:

Homesickness

Sleepwalking

Bed wetting (send extra bedding)

Car sickness

Does your child have any dietary requirements or restrictions?

Yes ____ No ____

If so, please describe:_____________________________________________________________________

Does your child have any allergies that may be of concern?

Yes ____ No ____

If so, please describe the severity:____________________________________________________________

Has the participant recently been ill or exposed to any communicable diseases? Yes ____ No ____

If so, please explain:_____________________________________________________________________

Student Medical Form