2019 EYM Student Health Form

HEALTH INFORMATION

Please list all allergies.

Conditions

Check "yes" or "no" for all conditions. Please comment below with more details.

ADD/ADHD *

YES NO

Anxiety or Depression *

YES NO

Asthma *

YES NO

Diabetes *

YES NO

Headaches, Migraines *

YES NO

Heart Defect/Disease *

YES NO

Kidney Disease *

YES NO

Muscular or Skeletal Disorder *

YES NO

Other

Comments on any conditions

List any prescription medications being taken, including dosage. Indicate the use of EpiPen or inhaler.

Please note that MITY staff and teachers cannot distribute prescription medications to any students participating in our programs with the exception of an EpiPen.

Student may be given the following if needed: *

Benadryl Ibuprofen Tylenol none

Explain any specific needs or accommodations for any known behavioral, physical, emotional and/or educational challenges:

Explain any dietary modifications:

List any activities that are limited by your child's physician:

Are all immunizations current? *

YES NO

Physician:

First Name Last Name

Phone Number:

Area Code xxx-xxxx

Preferred Medical Facility:

Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Insurance Company: *

Policy Number: *

Group Number: *

Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Authorization for Medical Care

This health history is correct so far as I know. The person herein described has permission to engage in all activities except as noted. I hereby give permission to the Adult-In-Charge to provide routine health care and witness prescribed medications. I consent for my child to receive such medical treatment and/or surgical procedures as are deemed necessary in the event of an emergency and to assume liability for any medical expenses involved. This authorization extends to my child’s participation in any activity sponsored by MITY. Should a medical emergency arise during my child’s participation in a MITY sponsored activity, I understand that reasonable efforts will be made to contact me or my designated alternate at the phone numbers I have given. If it is believed my child’s life or health may be adversely affected by the delay that an attempt to contact me or my designated alternate would cause, I consent to the administration of medical treatment and/or surgical procedure deemed necessary by the medical doctor and/or medical facility and the immediate administration of life-sustaining measures deemed necessary under the circumstances. This completed form may be photocopied.

Parent/Guardian Signature: *

Date:

Student's Name *

First Name Last Name

I authorize Minnesota Institute for Talented Youth to use any photos or video of my student for presentations, advertising, publicity and promotion. MITY will never use a student's name.

The student named above has my consent to take supervised field trips with MITY staff. I understand that necessary planning and precautions will be taken, and will not hold MITY or those supervising the trip liable for accidents or injuries associated with my student's participation.

The student named above has read and understands the MITY Code of Conduct. I understand that violations of these rules or any other inappropriate conduct may result in discipline, including dismissal from the program. Students who are asked to leave the program for discipline issues will not receive a tuition refund.

Parent/Guardian Signature: *

Date:

2021 EYM Student Health Form

CONSENT AUTHORIZATION