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Select Page
  • Student Health Form

    The following is required for every Odyssey participant. Incomplete health forms will result in the participant's inability to participate in field trips and/or certain physical activities. Please complete the following based on the participant.
  • In inches, please. Numbers only. No special characters, spaces, or text.
  • Numbers only. No special characters, spaces, or text.
  • Please provide the name of the individual we need to contact first in the event of an emergency.
  • First number we need to contact in the event of the emergency
  • If you choose, please add an additional emergency contact number in the event of an emergency.
  • Who should we email in the event of a campus-wide emergency?
  • Is there anyone else we should email in the event of a campus-wide emergency?
  • Participant Health History Section

    The following should be completed based on the participant's health history.
  • Participant's most recent Tetanus Booster received
  • Does the participant have a MEDICAL sensitivity to extreme (summer) heat?
  • Has the child ever been admitted to the hospital for heat stroke or is the doctor aware of the concern?
  • Select any food allergy restrictions from the list below. If no food allergies are known, select the first option. Tip: to make multiple selections--> Press and hold "Command" key ( Mac) or "Control" key ( Microsoft )
  • Are there any additional FOOD allergies not listed above that need to be added to the student's file?
  • Please list the additional FOOD allergies. Click the "+" button for each restriction.
    Food Allergy 1Food Allergy 2Food Allergy 3 
  • Select as many dietary restrictions that apply. If no restrictions, select the first column. Vegans have access to a daily salad/sandwich bar. Vegetarians have daily hot lunch option.
    Tip: to make multiple selections--> Press and hold "Command" key ( Mac) or "Control" key ( Microsoft )
  • Please list additional DIETARY restrictions. Click the "+" button for each restriction.
    Dietary Restriction 1Dietary Restriction 2Dietary Restriction 3 
  • Please be as brief as you can. This note will only be aviailable to office and nursing staff.
  • If none, write in "N/A" or "No Known Illness"
  • If none, write in "N/A" or "No Known Illness"
  • If none, write in "N/A" or "No Known Illness"
  • Does the participant take any current medications? This includes medicines taken at home in addition to school or play.
  • Please list ALL current medications, even if they are not administered during the program. Click the "+" button for each restriction.
    Medication 1Medication 2Medication 3 
  • I understand that all medications must be brought to Odyssey in the original prescription container bearing the child’s name, physician’s name, type of medication, and prescribed dose. Include a note detailing specific instructions for distribution.
  • Insurance

    Please provide the following insurance information in case of emeregency.
  • Doctor of Physician's Office Phone
  • Numbers only. No special characters, spaces, or text.
    Use this field for health insurance policy numbers without letters.
  • Use this field for health insurance policy numbers with a combination of text and numbers.
  • Thank you for completing the health form

    Please thoroughly read the below agreements before submitting this health form.
  • I am the parent or legal guardian of this minor child. I certify that this health history is correct so far as I know and that he/she has no past or current physical or psychological problems that would negatively affect or prohibit participation in any activities. My child has permission to engage in all Odyssey 2018 activities including strenuous walking, long hours outdoors and field trip travel. I understand I am responsible for informing Odyssey of medical issues that arise between now and the start of Odyssey. I am responsible for medical bills that result from my child becoming sick or injured at Odyssey. I give permission for Odyssey to administer over-the-counter (OTC) medications such as Tylenol, Pepto Bismol, Immodium AD, Ibuprophen, Calamine Lotion, or CortAid if the camp nurse or EMT deems it necessary. Exceptions are noted above. OTC Medications are used according to manufacturer directions unless a physician directs otherwise. If I cannot be reached in an emergency, I hereby give permission to the physician selected by Odyssey to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child. *Your agreement is considered a signature.
  • This field is for validation purposes and should be left unchanged.
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