After School Program Health History Form (Page 2 of 2) in pdf

HEALTH HISTORY FORM Pg. 2 of 2

THE SALVATION ARMY

After School Program

Name:

Corps/Unit:

Diet / Nutrition

Allergies

List dietary restrictions

List all allergies and reactions

No known allergies

Eats a regular vegetarian diet

Eats a regular diet

Has special food nee d s or allergies (describe below)

List activity restrictions

Restrictions

Medications

List of medicines that will need to be administered after school.

Must be in original container include name, dose and frequency.

I have reviewed the program and activities and feel the

No medications

child can participate without restrictions.

I have reviewed the program and activities of the and feel the child

can participate with the following restrictions or adaptations:

Past Medical / Surgical History / Current Medical Treatment

This health history is correct and accurately reflects the health status of the person to whom it pertains. The person herein described has permission to

engage in all After School Program activities except as noted. I hereby give permission to the physician selected by the After School Program to order x-rays,

routine tests and treatment related to the health of my child/myself for both health care and emergency situations. In the event I cannot be reached in an

emergency, I hereby give permission to the physician to hospitalize, secure proper treatment for and order injection, anesthesia, or surgery for the person

named above. I give permission to the After School Program to arrange necessary related transportation for my child/me. I understand the information on

this form will be shared on a "need to know" basis with student staff. I give permission to photocopy this form. In addition, the After School Program has

permission to obtain a copy of my child's/my health record from providers who treat my child/me and these providers may talk with the program's staff about

my child's/my health status. In accordance with Federal law, I understand that my consent is valid for up to one (1) year from the date of signature. My

consent can be revoked at any time upon The Salvation Army's receipt of my written revocation.

Printed Name of Parent /Guardian OR Adult Participant

Signature of Parent /Guardian OR Adult Participant

Date