Student Medical Form Nyc Minority Program (Page 4 of 4) in pdf

Note: Participation in the Institute will require some physical exertion, including hiking, walking, and other physically and

mentally demanding efforts. Several times during the Institute, the coursework will take students to somewhat isolated areas

without immediate access to medical facilities or medical staff. Given the above, please list all physical or mental limitations

and/or restrictions of which you are aware:

_________________________________________________________________________________________________

Important: If you have no limitations or restrictions, please sign here: __________________________________________

TETANUS:

The danger of tetanus in natural areas can sometimes be severe. You must be inoculated against this fatal disease and

you need a booster every ten (10) years.

Give the date of your most recent tetanus inoculation or booster: ___________________________________________

PHYSICAL EXAMINATION

A recent physical examination is recommended and may be required by NHEC.

Date of most recent physical: _________________________________________________________________________

Doctor’s name: ____________________________________________________________________________________

Address: _________________________________________________________________________________________

City, State____________________________________________________ Zip __________________________________

Phone Number: ____________________________________________________________________________________

SHIRT SIZE:

All students will receive a polo type shirt for use during and after the Institute. Please tell us your shirt size (check one):

❑ Small

❑ Medium

❑ Large

❑ XLarge

APPLICANT’S SIGNATURE: _________________________________________Date: ____________________________

PARENT OR LEGAL GUARDIAN SIGNATURE: __________________________________________________________

Date: ____________________________________________________________________________________________

(Required for all Applicants, even if you are over 18).

(PARENTS—you must sign your name clearly).

REMEMBER: Be sure to include this form with your application.

Student Medical Form Nyc Minority Program Page 4