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Microsoft word - form 6.docx

State/Country:
Last, First Middle – Must Match Your Identification Documents
Spell Out
The information collected on this form is necessary to identify and provide appropriate medical care; provide complete information so that the
Foundation can be aware of individual needs. The information provided is protected as required by the Health Insurance Portability and
Accountability Act (HIPAA)
. Any changes of the information on this form after it is submitted must be provided to the National Youth Science
Foundation upon the participant’s arrival. You are required to provide proof of medical insurance coverage. This is accomplished by submitting
a copy of both sides of your medical insurance card. Be sure that the insurance card provides the following information: policy holder’s name and
address, employer’s name, policy and/or group number, and the name and address of the insurance company. Please notify the Foundation if the
participant is exposed to any communicable disease during the four weeks prior to arrival.
(This portion to be filled out by parent or legal guardian and checked with physician at the time of examination)
Emergency contact, if parent not available: Explain any restrictions to activity (e.g. what can not be done, what adaptations or limitations are necessary: Permission to Provide Medical Treatment or Emergency Care:
As the legally recognized parent or guardian of the individual named above, by signature below, I hereby give authority and permission to the
National Youth Science Foundation, its staff, and licensed medical professionals to obtain and provide necessary medical treatment, including, but
not limited to, diagnostic X-rays, routine tests, and treatment, including hospitalization; to release any records necessary for medical or insurance
purposes; to provide or arrange necessary related transportation for my child; to administer, as needed, the over-the-counter medications listed
below (strike through any exceptions); and to copy this completed form (to accompany the participant on trips outside of our facility). I understand
that every practical effort will be made to contact me or other parents or guardians of the participant if a medical emergency occurs.
Over-the-Counter Medications and indications:

Robitussin (Guifenesin), per weight/age dosing for cough Benadryl (Diphenhydramine) oral, per directions for weight/age for rash/itch, rhinitis, sneezing, itchy eyes without acute asthma episode Tylenol, per weight/age dosing, for pain, fever, headache Calamine/Anti-itch lotion, topically, for itch/contact dermatitis Throat Bacitracin/Triple Antibiotic Ointment, topically, for wound care Dramamine (Dimenhydrinate)/meclizine, for motion sickness Epinephrine and Benedryl, for severe anaphylactic reaction Please remember to enclose a copy of both sides of your medical
I understand and agree to the above and to abide by any and all
insurance card along with this completed form.
restrictions placed on my camp activities.
General Questions
Has/does the participant:
1. Had any recent injury, illness or infectious disease? 15. Ever been diagnosed with a heart murmur? 2. Have a chronic or recurring illness/condition? 17. Ever had problems with joints? (e.g. knees, ankles)? 21. Had mononucleosis in the past 12 months? 8. Wear eyeglasses, contacts, or protective eye wear? 22. Had problems with diarrhea/constipation? 10. Ever passed out during or after exercise? 24. If female, have an abnormal menstrual history? 11. Ever been dizzy during or after exercise? 13. Ever had chest pain during or after exercise? 27. Ever had emotional difficulties requiring professional help? Please explain any "yes" answers, noting the number of the questions (attach additional pages as necessary).
PLEASE RETURN EACH FORM AS SOON AS IT IS COMPLETED, SEPARATELY IF NECESSARY. NATIONAL YOUTH SCIENCE FOUNDATION® • P.O. BOX 3387 • CHARLESTON, WV 25333-3387 State/Country:
Last, First Middle – Must Match Your Identification Documents
Spell Out

Immunizations (Please fill out as completely as possible.)
Which of the following
Please give all dates of immunization for:
Physical Examination (This portion to be filled out by a licensed health care provider prior to delegate's arrival at camp.)
A check mark () indicates "satisfactory." Please explain unsatisfactory categories – attach additional pages as necessary.
Posture (spine) Recommendations and Restrictions:
Allergies
– List all known allergies, describe reaction, and describe management of the reaction
Medication allergies

Food allergies

Other allergies
(Please include insect stings and environmental allergies)

Medications being taken

Please list ALL medications, including over-the-counter or non-prescription drugs, taken routinely. Bring sufficient amounts of medication to last the
entire time at camp. Keep it in the original package or bottle that identifies the prescribing physician (if a prescription drug), the name of the
medication, the dosage, and the frequency of administration.
○ This person takes NO medications on a routine basis, or
○ This person takes medications as follows (please attach additional pages as necessary):
Med #1
Examining Provider's Information
(please print or type)
Telephone number (including area code)
Examining Provider’s Signature

Don’t forget to attach a copy of your medical insurance card!!!
This health history is correct and complete as far as I know.

Parent or LegalP LEA
re CH FORM
nt , sSE
e ELY IF NECE SSARY. Date
NATIONAL YOUTH SCIENCE FOUNDATION® • P.O. BOX 3387 • CHARLESTON, WV 25333-3387

Source: http://2012.nysc.org/wp-content/uploads/2012/03/Form-6.pdf

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