Student Medical Information Form

Medical Information Form
The following information is requested so that RSYTC’s staff or their agents employed to support our camps (known henceforth as “agents”) can make sensible decisions about administering basic medical care/first aid where necessary.

For any and all serious incidents, RSYTC's staff would of course act only on the advice of qualified medical personnel and every attempt would be made to contact you first. However, should we or the medical staff be unable to contact you immediately, the information below will help us to make swift, informed decisions about the welfare of your child.

Please fill out all boxes as completely as possible now.

You are responsible for keeping our office updated of any changes to the information below, including contact numbers. For your child’s health and welfare, it is important that this form is as up-to-date as possible.

Student Information
Student's Name*

First NameLast Name
Date of Birth*

DayMonthYear
Grade*
Emergency Contact Details
Contact Person*

First NameLast Name
Relationship to child*
Home phone*

Area CodePhone Number
Mobile phone*
Email or other
Medical Details
Health Insurance Provider*
Address of Provider*
Policy number or plan*
Family Doctor
Doctor's Name*

First NameLast Name
Address*
Contact number*

Area CodePhone Number
Pre-existing medical condition?*

YesNo
Details
Regular medication?*

YesNo
Details
Allergy sufferer?*

YesNo
Details
Does your child have any emotional, social, or mental condition(s) that we should be aware of?*
I/we give permission for our child to be given medication for minor conditions such as headaches, menstrual cramps (Tylenol, Advil - children's or adult), nausea (Kaopectate, Pepto-Bismol), allergic reactions (Zytrec, Benadryl), should my child request it.

YesNo
List here any exceptions i.e. medication that you know your child is allergic to or is otherwise

Special Dietary Requirements
On occasion, RSYTC may order pizza or ice cream for the kids or bring in treats (cookies, cake, etc.). Does your child have any special dietary requirements? e.g. vegetarian, lactose intolerant, gluten/celiac, etc.*

YesNo
Details

General Declaration
The following information is requested so that RSYTC's staff or their agents employed to support our camps (known henceforth as “agents”) can make sensible decisions about administering basic medical care/first aid where necessary.

For any and all serious incidents, RSYTCs staff would of course act only on the advice of qualified medical personnel and every attempt would be made to contact you first. However, should we or the medical staff be unable to contact you immediately, the information in this form will help us to make swift, informed decisions about the welfare of your child.

Please fill out all boxes as completely as possible now. You are responsible for keeping the school office updated of any changes to the information below, including contact numbers.
For your child’s health and welfare, it is important that this form is as up-to-date as possible.

We share medical data just for purpose of health of your child with medical personnel.

Your child’s medical data will be deleted one year after your child’s end of attendance.
The Parent listed as the Parent or Guardian above should complete the boxes on the right and sign below.
In signing this form, I give permission for my son/daughter to participate in all activities relating to the camp (including at singing, dancing, acting, rehearsing. Attach any exceptions in writing here and I acknowledge that exemption may only be possible with proof of a medical certificate.*

YesNo
Separate details to be attached

Upload a File

Cancelof
I hereby give permission to RSYTC’s staff and their agents to authorize on my behalf any emergency medical care (including surgery) which, on the recommendation of qualified medical personnel, may be deemed necessary. In such circumstances, I understand that RSYTC’s staff or their agents will seek to advise me at the earliest possible convenience.*

YesNo
Confirmation:

To the best of my knowledge, the information I have given above is correct. I will make every attempt to keep RSYTC's office updated of any changes to this form throughout the summer (if any).
Parent or Guardian*

First NameLast Name
Date*

MonthDayYear
Signature of Parent or Guardian (valid as paper and pen signature)*
Enter the message as it's shown*
Should be Empty:

Medical Information Form

Student Information

Emergency Contact Details

Medical Details

Special Dietary Requirements

General Declaration

Confirmation: