2023 State Health History Form - Recreation Station

Health History for Children and Youth Attending School Age Programs

Recreation Station
As required by K.A.R. 28-4-590(d) (1), each operator shall obtain a health history for each child or youth, on a form supplied by the department or approved by the secretary. Each health history is to be maintained in the child's or youth's file on the premises. As required by K.A.R. 28-4-590(d2), each operator shall require that each child or youth attending the program has current immunizations as specified in K.A.R. 28-1-20 or has an exemption for religious or medical reasons. Complete one form for each child or youth attending the School Age Program.
First and Last Name of the Child or Youth*
Gender*
Date of Birth (MM/DD/YYYY)*

MonthDayYear
Date
First Day at Recreation Station (Select May 30th if you are not sure)*

MonthDayYear
Date
First and Last Name of the Child's or Youth's Parent or Guardian*
Email
example@example.com
Home Phone #*
Home Address*

Home Street Address

Street Address Line 2

CityState / Province

Zip Code
Work Phone #
Work Address

Work Place Name & Street Address

Street Address Line 2

CityState / Province

Zip Code
Does child have a 2nd parent/guardian?*
First and Last Name of the Child's or Youth's 2nd Parent or Guardian*
Home Phone #*
Is address the same as Parent/Guardian listed above?

YesNo
Home Address*

Home Street Address

Street Address Line 2

CityState / Province

Zip Code
Work Phone #
Work Address

Work Place Name & Street Address

Street Address Line 2

CityState / Province

Zip Code
Names and ages of other children in the Child or Youth's Family

Person(s) authorized to pick up child in case of an emergency. This should NOT include Parents or Guardians.
Person 1 (Not a parent or guardian)*
Street Address*
Phone Number*
Please enter a valid phone number.
City*
Zip Code*
Person 2
Street Address
Phone Number
Please enter a valid phone number.
City
Zip Code
Person 3
Street Address
Phone Number
Please enter a valid phone number.
City
Zip Code

Immunizations Status
Did your child or youth attend a public school or accredited non-public school in Kansas, Missouri or Oklahoma?*

YesNo
If yes, are the child or youth immunizations current?*

YesNo
If no to either of the above questions, you must email a copy of the child or youth's immunization history to the Program Supervisor: ashlynn@derbyrec.com
Print the First and Last Name of the Person Completing this Health History form*
Relationship to the Child/Youth*
Date Completed*

MonthDayYear
Date
If the Health History form was completed by a person other than a Parent/Guardian, who provided you with this information?
What is that person's relationship to the child/youth?
I attest, under penalty of perjury, that to the best of my knowledge, the information provided on this form is true and correct.
Signature of person completing this form*

Clear
Date Signed*

MonthDayYear
Date

Authorization for Emergency Medical Care
Written permission for emergency medical treatment must be on file at the facility. Reference K.A.R. 28-4-127(b1A School Age Programs reference K.A.R. 28-4- 582(e2
I authorize Derby Recreation Commission and Recreation Station staff who is representative of the above-named facility to give consent for any and all necessary emergency medical care for my child or youth while child or youth is in the facilities' custody. (Enter Child's First and Last name)*
Enter Childs First and Last Name
First Day at Recreation Station*

MonthDayYear
Date
Last Day at Recreation Station (If not sure, select August 4th, 2023)*

MonthDayYear
Date
Health Insurance Information
My child is covered by health insurance*

YesNo
Health Insurance Policy Name*
Policy Number*
My child is covered under medical assistance*

YesNo
Medical Assistance Program*
Card Number*
My child is covered by Military Medical Care*

YesNo
Military Medical Care I.D. Number*
List any known allergies or other information about the medical conditions of this child or youth pertinent in case of emergency
Signature of Parent or Guardian*

Clear
Date*

MonthDayYear
Date

Medication Form
Authorization for Dispensing Medications to Children and Youth Long-Term Medications (Prescription and Non-Prescription)

Prescription medications must be in their original containers labeled with the child's/youth's first and last name; the name of the licensed physician, physician assistant (PA), or advanced practice registered nurse (APRN) who ordered the medication; the date the prescription was filled; the expiration date of the medication; and specific, legible instructions for administration and storage of the medication. Administer the medication only to the child designated on the prescription label in accordance with the instructions on the label. Non-prescription medications can be given with written permission and direction from the parent or legal guardian. Administer nonprescription medication from the original container labeled with the first and last name of the child/youth and according to the instructions on the label.
First and Last Name of Child/Youth*
Date of Birth*

MonthDayYear
Date
Reason for Medication*
Name of Medication (only one medication per authorization)*
Prescription OR Non Prescription*
Dose*
Time to be Given*
Start Date*

MonthDayYear
Date
Stop Date**

MonthDayYear
Date
Name of Licensed Physician, PA or APRN prescribing the medication*
Phone # of Physician, PA or APRN*
Parent's Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Health History for Children and Youth Attending School Age Programs

Person(s) authorized to pick up child in case of an emergency. This should NOT include Parents or Guardians.

Physician and Medication Information

Immunizations Status

Authorization for Emergency Medical Care

Health Insurance Information

Medication Form