Student Medical Form

Student Name:

MEDICAL

Does your child have a doctor or nurse practitioner?*

Yes
No

Name of child’s doctor or nurse practitioner

Phone

In the past 12 months, did you have problems obtaining medical care for your child?

Yes
No

INSURANCE

Does your child have medical insurance coverage?*

Yes
No
Don’t know

Name of provider

MEDICAL HISTORY

Have you ever been told by a physician or health care professional that your child has:

Other

Does your child experience any of the following?

Do any of the above condition(s) limit/effect your child?

LIFE-THREATENING CONDITIONS

Does your child have a life-threatening health condition? Yes * No If Yes, Describe:

ALLERGIES

Plants
Animals
Food
Molds
Drugs
Bees

Other

Please 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/LANGUAGE

Do you have concerns about your child's speech and/or language?

Yes
No

Do others have difficulty understanding your child?

Yes
No

____If yes, please explain

AUTHORIZATION 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

This questionnaire is designed to aid WYF volunteers and mentors in anticipating any health concerns that might affect your child’s safety or learning.