This questionnaire is designed to aid WYF volunteers and mentors in anticipating any health concerns that might affect your child’s safety or learning. Student Name:MEDICALDoes your child have a doctor or nurse practitioner?*YesNoName of child’s doctor or nurse practitionerPhoneIn the past 12 months, did you have problems obtaining medical care for your child?YesNoINSURANCEDoes your child have medical insurance coverage?*YesNoDon’t knowName of providerMEDICAL HISTORYHave you ever been told by a physician or health care professional that your child has: Asthma Seizure disorder Bleeding disorder ADD/ADHD Diabetes Bone/muscle disease Skin condition Learning disability Heart condition Mental health condition (i.e., depression, anxiety, eating disorder) OtherDoes your child experience any of the following? Nose bleeds Frequent ear aches Overweight for age Physical disability Poor appetite Frequent stomach aches Frequent headaches Fainting spells Tires easily Emotional concerns Underweight for age Do any of the above condition(s) limit/effect your child?LIFE-THREATENING CONDITIONSDoes your child have a life-threatening health condition? Yes * No If Yes, Describe: ALLERGIES Plants Animals Food Molds Drugs Bees OtherPlease describe the allergic reaction and the treatment for each checked allergy WYF provides breakfast during each session. Meals are also served on WYF outings. *an additional form must be completed for food allergies MEDICATION Does your child take any medication? Yes ____ No ____ If yes, name of medication: Purpose Will medication be needed during any sessions/outings?SPEECH/LANGUAGEDo you have concerns about your child's speech and/or language?YesNoDo others have difficulty understanding your child?YesNo____If yes, please explainAUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT I understand the information given above will be shared with appropriate individuals (volunteer/mentors of WYF) to provide for the health and safety of my child. If either I or an authorized emergency contact person cannot be reached at the time of a medical emergency, I authorize WYF volunteers/mentors to send my child to the most easily accessible hospital or physician. I understand I will assume full responsibility for payment of any transport or emergency medical services rendered.Parent/Guardian signature:Date Captcha