SCYR Medical History/Consent Form

SCYR Medical History/Consent Form
IMPORTANT: This form must be completed and returned before your child can attend Localogy programs. A physical examination is not necessary before attending. The participant's medical history must be current (forms are updated annually, even for returning participants)
PARTICIPANT INFORMATION
Name*

First NameLast Name
Sex
Date of Birth*

MonthDayYear
Date
Age at start of program
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number
EMERGENCY CONTACT
Parent/Legal Guardian #1

First NameLast Name
#1 Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
#1 Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
#1 Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
#1 Email
example@example.com
Parent/Legal Guardian #2

First NameLast Name
#2 Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
#2 Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
#2 Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
#2 Email
example@example.com
If parent/guardian cannot be reached in an emergency notify:

First NameLast Name
#3 Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
#3 Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
#3 Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
#3 Email
example@example.com
Primary Physician Name
Physician Phone
Please enter a valid phone number.Format: (000) 000-0000.
Dentist Name
Dentist Phone
Please enter a valid phone number.Format: (000) 000-0000.
Orthodontist Name
Orthodontist Phone
Please enter a valid phone number.Format: (000) 000-0000.
INSURANCE
Is the participant covered by medical/hospital insurance?*

yesno
Insurance Company Name
Insurance Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name of Primary Plan Holder and Relationship to Participant
Policy Number / Group Number
MEDICAL HISTORY

Has/Does the participant:

Rows	yes	no
Ever been hospitalized?
Ever had surgery?
Have recurrent/chronic illnesses?
Had a recent infectious disease?
Had a recent injury?
Had asthma/wheezing/shortness of breath?.
Have diabetes?
Had seizures?
Had headaches?
Wear glasses, contacts, or protective eyewear?
Had fainting or dizziness?
Passed out/had chest pain during exercise?
Had mononucleosis (“mono”) during the past 12 months?
If female, have problems with periods/menstruation?
Have problems with falling asleep/sleepwalking?
Ever had back/joint problems?
Have a history of bedwetting?
Have problems with diarrhea/constipation?
Have any skin problems?
Traveled outside the country in the past 9 months?

Please explain any "yes" answers to the above questions:
MENTAL, EMOTIONAL, SOCIAL HISTORY

Has the participant:

Rows	yes	no
Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)?
Ever been treated for emotional or behavioral difficulties or an eating disorder?
During the past 12 months, seen a professional to address mental/emotional health concerns?
Had a significant life event that continues to affect the participant's life? (History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, change of residence, etc.)

Please explain any "yes" answers to the above questions:
VACCINATION HISTORY
The participant is up to date on the following recommended vaccinations (Select all that apply):*

Diptheria, tetanus, pertussis(DTaP) or (TdaP)Tetanus booster (dT) or (TdaP)Mumps, measles, rubella(MMR)Polio(IPV)Haemophilus influenzae type B(HIB)Pneumococcal(PCV)Hepatitis BHepatitis AVaricella(chicken pox)Had chicken poxMeningococcal meningitis(MCV4)The participant has not been fully immunized, and I understand and accept the risks to my child from not being fully immunized.
MEDICATION
“Medication” is any substance a person takes to maintain and/or improve their health. This includes prescription medication, non-prescription medication, vitamins & natural remedies. Please send any medication in the original packaging. Provide enough of each medication to last the entire time the participant is in the program. All medication must be turned in to Localogy staff as soon as the participant arrives and/or comes under our care. Participants are not permitted to keep and self-administer medications.*

The participant will not bring medication.The participant will bring medication (describe below).

Please list all medications:

Rows	Medication Name	Reason for Taking	Amount or Dose Given	When it is Given	How it is Given
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5

Do you authorize Localogy staff to administer other non-prescription medication to the participant as needed to manage illness or injury?*

yesno
ALLERGIES
Does the participant have any allergies? Select all that apply:*

No known allergiesAllergic to foodAllergic to medicationAllergic to the environment (insect sting, hay fever, pet hair, etc.)
Please describe any allergy selected above (cause, reaction, severity of reaction, management of reaction, etc.)
DIET/NUTRITION
Select all that apply:

VegetarianVeganLactose intolerantGluten freeOther
SPECIAL RESTRICTIONS/REQUIREMENTS
Does the participant require any special supervision, restriction, physical accommodation, or emotional accommodation? If yes, please explain:
CONSENT
I, First Name* Last Name*, affirm that this health history is correct and complete as far as I know. The person herein described has permission to engage in all program activities except as noted. I hereby give permission to Localogy staff to provide routine and emergency health care, and administer the medications as listed above. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. I give permission to Localogy staff to arrange necessary related transportation, and hospitalization for my child. I hereby give permission to the physician(s) selected by Localogy staff to administer necessary treatment, including hospitalization, medications, diagnostic tests, anesthesia, and surgery for my child named above. I understand the information on this form will be shared on a “need to know” basis with camp staff. I give permission to duplicate this form. In addition, the camp has permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status.
ParentGuardian Signature*
Date*

MonthDayYear
Date
Should be Empty:

SCYR Medical History/Consent Form

PARTICIPANT INFORMATION

EMERGENCY CONTACT

INSURANCE

MEDICAL HISTORY

MENTAL, EMOTIONAL, SOCIAL HISTORY

VACCINATION HISTORY

MEDICATION

ALLERGIES

DIET/NUTRITION

SPECIAL RESTRICTIONS/REQUIREMENTS

CONSENT