Cat Pack Health History for Children and Youth Attending School Age Programs

Health History for Children and Youth Attending School Age Programs

Mulvane Recreation Commission
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.
Child's Name*

First NameLast Name
Gender*
Date of Birth (MM-DD-YYYY)*

MonthDayYear
Date
1st day attending MRC Program*

MonthDayYear
Date
Parent/Guardian Name*

First NameLast Name
Email
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
YesNo
Name and age(s) of other child(ren) in child's family.*

Person(s) authorized to pick up child in case of an emergency. This should NOT include Parents or Guardians.
Authorized Person #1 (NOT a parent)*

First NameLast Name
Authorized Person #1 Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorized Person # 1 Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Person #2

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Immunization Status
YesNo
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: cbeynon@mulvanerec.com
Full name of person completing this Health History Form*

First NameLast Name
Relationship to the Child*
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*

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Date*

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 Mulvane 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 Child's First and Last Name
1st Day at Cat Pack*

MonthDayYear
Date
Last day at Cat Pack (If not sure, select 5/25/2026*

MonthDayYear
Date
Health Insurance Information
YesNo
Insurance Policy Name*
Policy Number*
YesNo
Medical Assistance Program
Card Number
YesNo
Military Medical Care ID Number
List any known allergies or other information about the medical conditions of this child or youth pertinent in case of emergency
Signature*

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Date*

MonthDayYear
Date
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Health History for Children and Youth Attending School Age Programs