2024 PCC Health Form

PCC Health Form

This form is mandatory for the student to attend PCC. If on move-in day it is not done, the student will not be able to get their rooming assignment. Thank you for your attention to this. Any questions, please contact us or your student's primary care doctor. This form is HIPPA compliant and confidential and will be used only by Staff to provide care to your student. If you student will need medication at the program, HEALTH FORM #2 will be needed to filled out as well.
Student Name*

First Name/Preferred Name Last Name
Student Birthdate*

MonthDayYear
Date
Student's Gender Identity*

FemaleMaleNon-Binary
PCC Student ID #: (This is located on student's acceptance letter)*

Has/does the participant:*

	YES	NO
1. Had any recent injury, illness or infectious disease?
2. Have a chronic or recurring illness/condition?
3. Ever been hospitalized?
4. Ever had emotional difficulties?
5. Ever engaged in self-harming behaviors (i.e. cutting)?
6. Ever had an eating disorder?
7. Ever had surgery?
8. Ever had a head injury?
9. Ever been knocked unconscious?
10.Ever had seizures?
11. Ever had high blood pressure?
12. Ever been diagnosed with a heart murmur?
13. Ever had back problems?
14. Ever had problems with joints (i.e. knees, ankles)?
15. Have any skin problems (i.e. itching, rash, acne)?
16. Have diabetes?
17. Have Asthma?
18. Had mononucleosis in the past 12 months?
19. Had problems with sleepwalking?
20. Had problems with diarrhea/constipation?
21. If menstruates, have an abnormal menstrual history?
22. Had Covid-19 in the past?
23. Has your student been vaccinated against COVID-19?

Please explain any "YES" answers, nothing the number of the question (If Yes #23, please list Covid vaccine(s) and amount)
Provide any additional information about the participant's behavioral, physical, emotional or mental health about which the camp should be aware.

We keep the following medications on hand. Please indicate if we have your permission to administer these medications at the discretion of the health care provider or designee. *

	YES	NO
Antihistamine (Benadryl)
Acetaminophen (Tylenol)
TUMS
Ibuprofen (Advil)
Cough Drops

PCC Physical & Immunization Records

All students attending PCC will be required to provide a recent physical within the last 18 months and thier immunization records. Per the Easton Board of Health. You will not be able to move into the program without these being uploaded here. This form is HIPPA compliant.

This is due by May 26th. We will only accept PDFs of this form. You can scan it from a computer or with your phone.

IPHONE USERS: Open the Notes app on your iPhone and select a note or create a new note > tap the Camera, then choose Scan Documents > place the document in view of the iPhone camera > adjust the scan to fit the page, then tap Keep Scan > Tap Save at the right bottom to save your scanned document.

ANDROID USERS: Just scan it using the Google Drive app and your device’s camera. Your scanned document is stored in Drive as a PDF.
Please Upload Immunization Records Here:*

Cancelof
If your student will require prescription medication while at PCC, you will have to fill out the following document:

PCC Health Form #2 (For Medication)

This is due by May 26th. We will only accept PDFs of this form. You can scan it from a computer or with your phone.

IPHONE USERS: Open the Notes app on your iPhone and select a note or create a new note > tap the Camera, then choose Scan Documents > place the document in view of the iPhone camera > adjust the scan to fit the page, then tap Keep Scan > Tap Save at the right bottom to save your scanned document.

ANDROID USERS: Just scan it using the Google Drive app and your device’s camera. Your scanned document is stored in Drive as a PDF.
If you already have Health Form #2 filled out, you can turn it in here:

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OTHER: (List any over-the-counter medicines your child may use at PCC). Parent must provide:
Name of Physician *
Physician Phone Number*
Please enter a valid phone number.
By signing your name here, you are signing this form electronically. *

Parent/Guardian First NameParent/Guardian Last Name
Today's Date*

MonthDayYear
Date
Should be Empty: