Specific Medical Information. The Parish will take reasonable care to see that the following information will be held in confidence. Chronic Conditions (e.g. Epilepsy; Diabetes) Allergic Reactions (e.g. Food, medications, plants, etc.) Dietary Restrictions Immunizations: Date of last tetanus/diphtheria immunization: Any physical limitations? Has the Participant recently been exposed to contagious disease or conditions, such as mumps, measles, chicken pox, etc.? If so, list date and disease or condition: You should be aware of these special medical conditions of the Participant:
Specific Medical Information. Church of Immaculate Conception and all Churches participating, will take reasonable care to see that the following information will be held in confidence. Allergic reactions (medications, foods, plants, insects, etc.): Immunizations-Date of last tetanus/diphtheria immunization: Does child have a medically prescribed diet? Any physical limitations? Has child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc.? If so, date and disease or condition: Any special medical conditions?
Specific Medical Information. The parish/school will take reasonable care to see that the following information will be held in confidence. You should be aware of these special medical conditions of my child: Allergies to medications, foods, plants, etc. Medically prescribed diet: Currently being treated for mental health issues: Other special medical conditions:
Specific Medical Information. Transfiguration Catholic Church will take reasonable care to see that the following information will be held in confidence. Allergic reactions (medications, foods, plants, insects, etc.): Immunizations: Date of last tetanus/diphtheria immunization: Does child have a medically prescribed diet? Any physical limitations? Has child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc.? If so, date and disease or condition: You should be aware of these special medical conditions of my child: BIG XXXXX YOUTH REGISTRATION / MEDICAL FORM X X Xxxxxx name Address City State Zip Home Phone # E-Mail Address _/ /_ Grade Age at Camp Birth date Retreat/Camp Session Date Year Church Sponsoring, if any Parent or Guardian Emergency Contact Person Emergency Home Phone Emergency Cell Phone Health Insurance Company Insurance ID # Group # Physician’s Name Phone Number HEALTH HISTORY– CHECK (X) THOSE THAT APPLY EPILEPSY HEART TROUBLE CHICKEN POX SKIN TROUBLE ASTHMA BED WETTING CONVULSIONS EAR TROUBLE EMOTIONAL PROBLEMS ALLERGIC TO: PENICILLIN INSECT STINGS OTHER (LIST) IMMUNIZATION RECORD—CHECK (X) IF IMMUNIZED AGAINST. POLIO WHOOPING COUGH SMALL POX MEASLES DIPTHERIA RUBELLA Date of Last Tetanus Booster LIST ANY ACYTIVITY RESTRICTIONS, DIETARY RESTRICTIONS, HEALTH PROBLEMS AND/OR MEDICATION (RX OR OTC) RELATING TO YOUR CHILD. PLEASE GIVE A DESCRIPTION OF ANY CURRENT PHYSICAL, MENTAL, OR PSYCHOLOGICAL CONDITIONS REQUIRING MEDICATION, TREATMENT, OR SPECIAL RESTRICTIONS OR CONSIDERATIONS WHILE AT CAMP. USE THE REVERSE SIDE OR AN ADDITIONAL SHEET. IMPORTANT IF THE HEALTH HISTORY IDENTIFIES HEALTH PROBLEMS OR ACTIVITY LIMITATIONS, A PHYSICAL EXAMINATION MUST BE PERFORMED BY A LICENSED PHYSICIAN WITHIN ONE YEAR BEFORE ADMISSION TO CAMP, INCLUDING INSTRUCTIONS RELATIVE TO THE LIMITATION OF THE CAMPER’S PARTICIPATION IN CAMP ACTIVITIES OR MEDICATION REQUIREMENTS. I UNDERSTAND THAT EVERY EFFORT WILL BE MADE TO PROTECT AND SAFEGUARD ALL GUESTS. I AGREE NOT TO HOLD BIG XXXXX XXXX LIABLE FOR ANY ILLNESS OR MISHAP FROM ANY CAUSE WHATSOEVER. I ALSO GIVE CAMP FULL AUTHORITY IN DEALING WITH CAMPER DISCIPLINE. I UNDERSTAND THAT ANY CAMPER DISREGARDING CAMP RULES IS SUBJECT TO BEING SENT HOME WITH NO REFUND OF CAMP FEES. I UNDERSTAND THAT ANY CAMPER WHO WILLFULLY DESTROYS PROPERTY WILL BE HELD RESPONSIBLE AND BE CHARGED ACCORDINGLY. BIG XXXXX XXXX MAY USE PHOTOS, VIDEO, OR COMMENTS, OF THE CAMPER NAMED ABOVE IN ITS PROMOTIONAL MATE...
Specific Medical Information. The parish or school will take reasonable care to see that the following information will be held in confidence. Allergic reactions (medications, foods, plants, insects, etc.): Immunizations: Date of last tetanus/diphtheria immunization: Does child have a medically prescribed diet? Any physical limitations? Is child subject to chronic homesickness, emotional reactions to new situations, sleepwalking bedwetting, fainting? Has child recently been exposed to contagious disease or conditions such as mumps, measles, chicken pox, etc.? If so, list date and disease or condition: You should be aware of these special medical conditions of my child:
Specific Medical Information. The parish/school will take reasonable care to see that the following information will be held in confidence. Allergic reactions (medications, foods, plants, insects, etc.): Immunizations: Date of last tetanus/diphtheria immunization: Does child have a medically prescribed diet? Any physical limitations? Has child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc? If so date and disease or condition: You should be aware to these special medical conditions of my child:
Specific Medical Information. The parish will take reasonable care to see that the following information will be held in confidence. Allergic reactions (medications, foods, plants, insects, etc.): _ Immunizations: Date of last tetanus/diphtheria immunization: Does child have a medically prescribed diet? Any physical limitations? Is child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, fainting? Has child recently been exposed to contagious disease or conditions, such as mumps, measles, chicken pox, etc.? If so, list date and disease or condition:
Specific Medical Information. If the Consenting Patient does not wish to authorize an indiscriminate release of all his or her medical information through this instrument of consent, he or she may limit the authorized release of medical information to only a specific topic or condition. For this effect, select the second checkbox statement from the Second Article. Additionally, this selection requires that the exact nature of the information the Patient authorizes for release is established on the blank space available.
Specific Medical Information. The School will take reasonable care to see that the following information will be held in confidence. Allergic reaction (medications, food, plants, insects, etc.): Immunizations: Date of last tetanus/diphtheria immunization: Does the child have a medically prescribed diet or is he or she vegetarian/vegan? Does your child have any physical limitations? Is your child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, fainting or the like? Has the child recently been exposed to contagious diseases or conditions, such as mumps, measles, chicken pox, etc.? If so, date and disease or condition: You should be aware of these medical conditions of my child: Signature: Date:
