Parent/guardian-Please Complete Form

Missouri University of Science and Technology Summer Enrichment Programs

YOUTH HEALTH STATEMENT FORM

Event ________________________________________________Dates of Event ______________________________________

Student Name __________________________________________________________________________Age ____ M ____ F ____ Birth Date _________________________

Ethnicity: ______ African American ______ Asian ______ Bi-Racial ____Caucasian _______Hispanic______ Native American _____ Pacific Islander ______ Other

Parent/Guardian Name __________________________________________Phone: Day # (

)________________________Evening # (

)___________________________

Home Address _______________________________ City _______________________ State ______ Zip __________ Home # (

) _________________________________

Health Insurance Company Name ____________________________________________________________ Group/Policy Number ___________________________________

If parent/guardian cannot be reached, list emergency contact:

Name ___________________________________________Relationship ___________________ Home # (

) __________________ Work # (

) _______________________

PARENT/GUARDIAN-PLEASE COMPLETE

1. Will your child be bringing any type of medicine to this event? ______Yes ______ No

If yes, give type and instructions _____________________________________________________________________________________________________________

2. Does your child have any allergies? ______Yes ______No

If yes, explain _____________________________________________________________________________________________________________________________

3. Describe any special needs (medical, physical or mental challenges) officials should be aware of in making this program safe and accessible for your child.

Explain ____________________________________________________________________________________________________________________________________

4. Does your child have any special dietary needs?

Explain ____________________________________________________________________________________________________________________________________

5. Does your child have any other restrictions or needs, not described above? ______________________________________________________________________________

6. Last tetanus immunization ___________ Family doctor_____________________________________ Phone (

) _______________________________________________

7. May your child be given pain relievers (such as Tylenol, Motrin, etc.)? ________Yes _______No

If necessary, I do approve of officials taking my child __________________________________________ to the nearest doctor or hospital. I further understand that should a

health problem arise, I will be notified, but that if I cannot be reached by telephone, such medical treatment, including surgery, as deemed necessary by competent medical

personnel, would be rendered.

Both youth and parent (guardian) must sign this form.

____________________________________________________

Youth’s Signature

Date

____________________________________________________

Parent/Guardian’s Signature

Date

Missouri University of Science & Technology is an Equal Opportunity Institution. For concerns about access or opportunity, contact Disability Support Services 573-341-4211. The Missouri University of Science & Technology

complies with the guidelines set forth in the Americans with Disabilities Act of 1990. If you have special needs as addressed by the Americans with Disabilities Act and need assistance with this or any portion of the enrollment process,

notify us at 573-341-4211. Reasonable efforts will be make to accommodate your special needs.