2024 NRECA Youth Tour Health Form

The following form is being completed for a

High School Youth Tour DelegateChaperone or other staff attending with a participating stateYouth Tour DirectorNRECA BlueShirt / Staff Assistant

Youth Tour Delegates and their parents / guardians must read the health form and attest the information given is true and complete.

Information cannot be saved and revisited later so please plan to complete the form together.

Please contact your state Youth Tour Director with any questions.

Participant Legal Name (as it appears on their state issued ID) *

First NameMiddle NameLast Name

Participant Date of Birth*

Date

Participant Phone Number

Area CodePhone Number

Participant Email

example@example.com

State with whom the participant is attending Youth Tour*

Sponsoring Co-op*

Participant's Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Legal Guardian Contact Information - Provide contact information for at least one parent / guardian. If attending as Staff, please list at least one emergency contact*

	First Name	Last Name	Best Phone Number	Email Address
Guardian 1
Guardian 2
Guardian 3
Guardian 4

Will the Youth Tour participant require regular medication (prescription, over-the-counter, inhaler, etc.) while attending Youth Tour?*

Note: Youth Tour & NRECA Nursing Staff will not dispense prescription medications to Youth Tour participants

Please list information for the participant's medication below making sure to detail any potential side effects or other concerns - including what could happen if a dose is missed. You will have the opportunity to list additional medications in the next field.

	Please list any relevant information here
Medication Name
Dosing Schedule
Does the participant require assistance?
Storage Instructions
Additional Comments

Does the participant require additional medications?

Please list information for the participant's medication below making sure to detail any potential side effects or other concerns - including what could happen if a dose is missed. You will have the opportunity to list additional medications in the next field.

	Please list any relevant information for medication #2 here
Medication Name
Dosing Schedule
Does the participant require assistance?
Storage Instructions
Additional Comments

Does the participant require additional medications?

Please list information for the participant's medication below making sure to detail any potential side effects or other concerns - including what could happen if a dose is missed. You will have the opportunity to list additional medications in the next field.

	Please list any relevant information for medication #3 here
Medication Name
Dosing Schedule
Does the participant require assistance?
Storage Instructions
Additional Comments

Does the participant require additional medications?

Please list information for the participant's medication below making sure to detail any potential side effects or other concerns - including what could happen if a dose is missed. You will have the opportunity to list additional medications in the next field.

	Please list any relevant information for medication #4 here
Medication Name
Dosing Schedule
Does the participant require assistance?
Storage Instructions
Additional Comments

Does the participant require additional medications?

Please list information for the participant's medication below making sure to detail any potential side effects or other concerns - including what could happen if a dose is missed. If the participant requires additional medication, please list them - along with any instructions & relevant information at the end of this form.

	Please list any relevant information for medication #5 here
Medication Name
Dosing Schedule
Does the participant require assistance?
Storage Instructions
Additional Comments

Does the participant have food, drug, or other allergies?*

Is there threat of an anaphylaxis - or other life-threatening - reaction if the participant comes in contact with or ingests the allergen?

NoYes - And they carry their EpiPen - or other lifesaving device - at all times

Please provide details for all allergens, including seasonal allergies, along with the participant's potential reaction and the detailed action plan, as directed by the participant's doctor:

Does the participant have any dietary restrictions or requirements?*

Food restrictions or requirements due to allergies, intolerances, diabetes, religious beliefs, or other

Please select any dietary restrictions, preferences, and requirements:

Please elaborate with any information that will help ensure the participant is accommodated effectively:

Please select any medical issues that may require special consideration or care by the nurses and Youth Tour staff:

Please elaborate with information to help our staff best accommodate the participant. Include dates of recent doctor visits and any follow-up recommendations & requirements.

The participant has no known medical issue - listed above or otherwise - that will require special consideration or prevent them from participating fully in the Youth Tour program.

Please confirm this by selecting this option

NRECA & Youth Tour nurses, staff, chaperones and directors have permission to dispense over-the-counter medication to the participant if they deem it medically appropriate (For example: ibuprofen, acetaminophen, heartburn relief, etc.) *

Note: NRECA nurses are not responsible for dispensing prescription medications

Please elaborate as you are comfortable:

Has the participant consulted with a medical professional regarding the Youth Tour program and been authorized to participate?

Please explain the restrictions or conditions OR share why the authorization is not necessary:

Youth Tour is a high-energy, physically taxing week of touring, networking, and experiencing the best our nation's capital has to offer. Does the participant have any other issues (including medication needs not listed above) that may limit their full engagement in the program? If yes, please use the space below to explain. If no, please confirm by writing "No."

You will receive and be expected to complete another short form prior to Youth Tour in June asking you to detail all illnesses and/or injuries occurring between completing this form and attending Youth Tour.*

I will complete and submit this form within the requested timeline

Youth Tour Delegates and Staff, PLEASE READ, check each box, and Sign:*

I attest the information above to be true and complete to the best of my knowledge.I authorize NRECA and the state associations to use the information contained in this form to provide care to me while attending the Youth Tour event as well as to develop appropriate safety protocols for the program.I further authorize NRECA and the state associations to share information contained in this form with Youth Tour chaperones, directors and nurses who have a need to know for the purpose of providing me care.I understand that to participate in Youth Tour, I must comply with all mandates and policies extended by NRECA, state and local governments, my state association, the venues, federal buildings, hotels, transportation systems, etc. involved in my Youth Tour experience, from the time I leave my home until I return.I will also willingly and truthfully submit information regarding other changes that may have occurred regarding my health and participation status, including illnesses or injuries.I understand that failure to adhere to any requirements or rules, including those listed here as well as those outlined or implied by NRECA staff, statewide and local electric cooperatives, venues, public spaces, etc. will be viewed as noncompliance and I will be subject to removal from the program and returned home, at my family's expense, prior to the program completion.

Signature*

PARENTS & GUARDIANS, PLEASE READ, check each box, and Sign:*

I attest the information above to be true and complete to the best of my knowledge.I authorize NRECA and the state associations to use the information contained in this form to provide care to my child while attending the Youth Tour event as well as to develop appropriate safety protocols for the program.I further authorize NRECA and the state associations to share information contained in this form with Youth Tour chaperones, directors and nurses who have a need to know for the purpose of providing care to my child.I understand that for my child to participate in Youth Tour, (s)he must comply with all mandates and policies extended by NRECA, state and local governments, my state association, the venues, federal buildings, hotels, transportation systems, etc. involved in my child's Youth Tour experience, from the time they leave my care until they return.I will also willingly and truthfully submit information regarding other changes that may have occurred in the health of my participant, including illnesses or injuries.I understand that failure to adhere to any requirements or rules, including those listed here as well as those outlined or implied by NRECA staff, statewide and local electric cooperatives, venues, public spaces, etc. will be viewed as noncompliance and my child will be subject to removal from the program and returned home, at my expense, prior to the program completion.

Signature*