Admission Form E: Student Health Form

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.

Scholar's Full Name

First Last

STUDENT Date of Birth*

MM

DD

YYYY

OdysseyID

Grade Level*

Sex*

Female
Male

Height*

In inches, please. Numbers only. No special characters, spaces, or text.

Weight*

Numbers only. No special characters, spaces, or text.

Primary Emergency Contact*

Please provide the name of the individual we need to contact first in the event of an emergency.

First Last

Emergency Phone*

First number we need to contact in the event of the emergency

Optional: Secondary Emergency Phone

If you choose, please add an additional emergency contact number in the event of an emergency.

Emergency Email*

Who should we email in the event of a campus-wide emergency?

OPTIONAL: Secondary Emergency Email

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.

Date of Last Tetanus Booster*

Participant's most recent Tetanus Booster received

MM

DD

YYYY

Heat Stroke*

Does the participant have a MEDICAL sensitivity to extreme (summer) heat?

Yes
No

Heat Stroke Follow-Up

Has the child ever been admitted to the hospital for heat stroke or is the doctor aware of the concern?

Yes
No

Food Allergy Restrictions: Select All That Apply*

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 )

Additional Allergies Not Listed?

Are there any additional FOOD allergies not listed above that need to be added to the student's file?

Yes
No

Follow-up: Additional Food Allergies Not Listed?

Please list the additional FOOD allergies. Click the "+" button for each restriction.

Food Allergy 1	Food Allergy 2	Food Allergy 3

Dietary Restrictions?*

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 )

Any other dietary restrictions?*

Yes
No

Additional Dietary Restrictions

Please list additional DIETARY restrictions. Click the "+" button for each restriction.

Dietary Restriction 1	Dietary Restriction 2	Dietary Restriction 3

Any other medical restrictions/concerns?*

Yes
No

Tell us what we need to know

Please be as brief as you can. This note will only be aviailable to office and nursing staff.

Chronic or Recurring Illness*

If none, write in "N/A" or "No Known Illness"

Operations or Serious Injuries*

If none, write in "N/A" or "No Known Illness"

Health Concerns or Activities to be Restricted*

If none, write in "N/A" or "No Known Illness"

Current Medications*

Does the participant take any current medications? This includes medicines taken at home in addition to school or play.

Yes
No

List Current Medications

Please list ALL current medications, even if they are not administered during the program. Click the "+" button for each restriction.

Medication 1	Medication 2	Medication 3

Parent Agreement:*

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.

Physician's Name*

Health Insurance Carrier*

Physician's Phone*

Doctor of Physician's Office Phone

Policy Number-If Numbers Only

Numbers only. No special characters, spaces, or text.
Use this field for health insurance policy numbers without letters.

Policy Number-Combination text and numbers

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.

AUTHORIZATION TO SECURE PROPER MEDICAL TREATMENT*

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.

Agree
Disagree

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Phone

This field is for validation purposes and should be left unchanged.