SOUTHWEST CONFERENCE UCC HEALTH FORM:  Year ’07-‘08

One health form is sufficient for Southwest Conference youth events and camp during the entire school year and following summer.  This form is to be completed by the parent/guardian for youth who are minors or are not legally responsible for  themselves.  Please type or print. 

Name

Social Security Number

Height

Weight

In case of emergency, notify

Relationship

Home phone

(    )

Other phone

(    )

Insurance and physician information

Insurance company

Policy number

Address

Phone

Name coverage is in:

Primary insured SSN

Physician

Phone

(    )

Immunizations (please give month/year)

Tetanus

     /

Polio

     /

DPT

    /

MMR

    /

Allergies (Please check yes or no)

Hay fever

□   Yes

□   No

Penicillin

□   Yes

□   No

Sulfa

□   Yes

□   No

Other drugs

□   Yes

□   No

Bee sting

□   Yes

□   No

Poison ivy/oak

□   Yes

□   No

Food

□   Yes

□   No

Other

Health concerns (Please check yes or no)

Asthma

□   Yes

□   No

Bed wetting

□   Yes

□   No

Sleep walking

□   Yes

□   No

Depression

□   Yes

□   No

Colds

□   Yes

□   No

Sinus condition

□   Yes

□   No

Sore throat

□   Yes

□   No

Ear infection

□   Yes

□   No

Cramps

□   Yes

□   No

Hyperventilation

□   Yes

□   No

Convulsions

□   Yes

□   No

Heart disease

□   Yes

□   No

Diabetes

□   Yes

□   No

Homesickness

□   Yes

□   No

Athlete’s foot

□   Yes

□   No

ADHD/ADD

□   Yes

□   No

Other:

Please explain any of the “Yes” responses or any other physical or emotional challenges

Recent illness or surgery

Recent exposure to communicable disease

Please explain any restrictions

Vegetarian

□   Yes

□   No

Special dietary needs:

Current medications

Conference policy requires all participants to turn in ALL medications (including acne medication), clearly marked with name, drug, and dosage, and in its ORIGINAL package or bottle, to the nurse/staff under whose supervision all medications will be administered.  If the participant is currently taking any medication, please provide the following information:

Medication

Dosage

Times to be taken

Medication

Dosage

Times to be taken

Medication

Dosage

Times to be taken

Consent and Emergency Treatment Authorization:

In the event that I cannot be reached in an emergency or I, myself, am injured or in need of emergency care, I do hereby give my consent for  the above youth /adult  to receive such emergency treatment as deemed necessary by an attending physician.

Signature of parent/guardian/adult participant

Date

Please note:

Over-the-counter or internally-administered medication of any kind (including aspirin and

Tylenol/acetaminophen) will not be administered to minors in attendance at events/camp without express permission of the parent/guardian or attending physician.  If you so authorize over-the-counter medication, please sign here:

Signature of Parent/guardian

Date