Footmarks Health Form

THE 4TH Please WRITE/PRINT LEGIBLY and return this form PAGE MUST BE COMPLETED BY YOUR PHYSICIAN/REGISTERED DOCTOR. to the School/Grade in charge of outdoor programs

This document assists us in identifying appropriate health

Footmarks requires the document to be attested by a Doctor to assure that the participant is in sound care, and to be able to contact parent, guardian, or alternate participate in a outdoor Education program and also give access to emergency medical health to attention in case of any eventualities. This health form is one important way of helping to ensure a if necessary. safe and experience for all participants. It is essential that we learn the physical and THE HEALTH HISTORY(FIRST 3 PAGES) must be enjoyable mental history of our participants so that we can be best prepared to deal with any situations that may filled out by parents/guardians of minor participants of arise. Our health form must be used. If we have any question about your ability to complete the program, we Footmarks Programs, You must respond to EVERY will call and discuss the matter with you and/or your physician. We do not refund costs of medical examinations or other expenses you incur while preparing for the outdoor program. question. Please write N/A if not applicable; do not leave To the best of my knowledge, this health history is correct, and the person herein described has permission to blank. All the information in the form will be dealt with engage in all prescribed camp and travel activities except as noted. I hereby give permission to High confidentiality Footmarks and/or medical personnel to provide, seek, and consent to routine health care, administration of prescribed medications, and emergency treatment for me/my child, as may be necessary, including but not limited to x-rays, routine tests and treatment, and /or hospitalization. I also give permission for the Program to arrange related transportation. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. It is my intention that the camp Doctor be treated as acting in loco parentis if the person herein named is a minor. Further, it is my intention that the appropriate representatives of the camp be treated as(personal representatives)for the purposes of disclosing protected health information pursuant to the privacy regulations to the disclosure to Program representatives of the protected health information of the person herein described, as necessary: (i) to provide relevant information to the program representatives related to the person's ability to participate in camp activities; and (ii) in the case of minors, to provide relevant information to the camp representatives to keep me informed of my child's health status. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the program to secure and administer treatment, including hospitalization, for the person named above. This completed form may be photocopied for trips out of program.

PART I - STUDENT CONTACT INFORMATION - please fill in ALL that apply: PART II - INSURANCE INFORMATION

NAME ___________________________ Datenot _____/_____/_______ Please Note:PARTICIPANT Each applicant must be covered by his/her own sickness and_____________________________ accident insurance and is responsible Male for anyFemale medical Birth expenses covered by insurance. LAST FIRST DAY MONTH YEAR The following questions be answered prior to participation. * Home addressMUST _______________________________________________________________________________________City __________________________

* REQUIRED: please attach an enlarged copy of your insurance card, front and back.

State/Province ________ Zip _________ Country ___________________ Subscriber's name ________________________________________ Name of Insurance Company ______________________________________________ Subscriber_s Place of Work ______________________________________________ Subscriber_s Date of Birth day________/mo________/yr_________ Group or certificate # ____________________________________________________ Identification # ____________________________________________ CUSTODIAL PARENT/GUARDIAN: (Primary contact): Ins. AddressName ____________________________________________________________City/State/Zip _____________________________________________ ______________________________________________ Relationship: ______________________________________ Does the insurance company require pre-authorization? Yes No If yes, Phone # (_______)_____________________________________________ Home address ________________________________________________________________________________________City __________________________ (If different from above)

State/Province ________ Zip _________ Country ___________________ Home Phone ________________________Cell Phone _________________________Work phone ___________________________ email: ______________________________ (MANDATORY): IF PARENT / GUARDIAN NOT AVAILABLE, PLEASE NOTIFYALTERNATE EMERGENCY CONTACT: Name ______________________________________________ Relationship: ______________________________________ Home address ________________________________________City __________________________ State/Province ________ Zip _________ Country ___________________ (If different from above)

Home Phone ________________________Cell Phone _________________________Work phone ___________________________ email: ______________________________

FOOTMARKS-HEALTH FORM FOR SCHOOL PROGRAMS-CONFIDENTIAL INFORMATION IMPORTANT: Signatures and dates below are REQUIRED for attendance.

Signature of either parent / guardian of participant, ____________________________________________Date ________________________ Printed Name ________________________________________________________________________ I also understand and agree to abide by any restrictions placed on my participation in camp activities. Signature of minor participant, _________________________________________________________ Date _______________________

PART III - ALLERGIES, MEDICATIONS, RESTRICTIONS Please keep a copy of the completed form for your records, and bring any changes to this form to health personnel or program, staff upon participant’s arrival at the beginning of the program. ALLERGIES " DO NOT leave this section blank! Medication allergies List all known Describe reaction and management of the reaction. (Please use a separate sheet if necessary). My child does not have any known medication allergies _________________________________________ _________________________________________ _________________________________________

_______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________

Food allergies List all known Describe reaction and management of the reaction. (Please use a separate sheet if necessary). My child does not have any known food allergies _________________________________________ _________________________________________ _________________________________________

______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________

Other allergies: Include insect stings, asthma, animals, etc.) Describe reaction and management of the reaction. (Please use a separate sheet if necessary).

Please supply your own epi-pens if required in response to an allergic reaction).

My child does not have any known other allergies

________________________________________ _________________________________________ _________________________________________

_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

MEDICATIONS *Please list below any medications the participant is using (including psychiatric, over-the-counter or nonprescription drugs). Bring enough medication to last the entire time at camp, and keep it in the original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration. (Please use a separate sheet if necessary).

This person takes NO medications on a routine basis. Med #1 ___________________________________ Dosage ________________________Specific times infirmary, taken eachand day_________________________________ GENERAL MEDICATIONS * The following over-the-counter medications may be kept in the Program in first Aid Kits. PLEASE LET US Med #2 ___________________________________ Dosage ________________________Specific times taken each day_________________________________ KNOW if you DO NOT want any of these medications to be administered to your child. Please let us know of substitutes for medications you do not want your Med to #3receive, ___________________________________ Dosage ________________________Specific times taken each day_________________________________ child and please supply those substitutes for your child. yes no Ibuprofen yes no Acetaminophen yes no Tums/Bismuth yes no Betadine yes no Antiseptic Ointment yes no Hydrocortisone cream

Program Areas: All medications will be held and distributed by the Teacher in charge. Please send all medications in original containers, along with written instructions use, dosage, etc. Indicate SAFE whetherMEDICATION you will mail orUSE bring medication, or if camper willread bring medication before the program. The Teacher in charge OURfor POLICIES REGARDING ARE AS FOLLOWS: (please carefully!) will be at check-in on opening day to receive medications and instructions. Footmarks encourages those students who are independent and capable of responsibly administering medication to themselves to continue to do so. Student should bring only as much prescription medication as they need for the program. Leaders/ yes no Benadryl/Benzocaine Program Doctors will carry backup yes supplies of life saving medications (i.e., inhalers, insulin, epinephrine, etc). Parents need to supply backup medications with no Caladryl yes instructions to leaders/Program Doctors. On parental request, leaders/Program doctors will administer medications to students, excepting medications that legally yes no Calamine lotion no cannot be administered by leaders/Teachers in charge. IN ALL CASES, parents must provide documentation of medications which are routinely taken by the student, yes no Calagel Epin interactions, contra-indications, and overdose protocol. PARENTS OF STUDENTS CHECK ALL THAT APPLY: no Benadryl ephri including instructions, dosage, drugyes yes no Aloe Vera

ne

yes no

My child is not taking any medication at this time. yes no I request the leaders to remind my child of self-administering. no My child will self-administer his/her own medications. yes no I request that the leaders hold and administer my child’s medications.

yes no

Burn yes Gel yes no Cough drops yes no Robitussin yes no Dayquil yes no Nyquil yes no Dental wax yes no Electrolytes yes no Immodium yes no White vinegar yes no Pepcid yes no Menthol

RESTRICTIONS The following restrictions apply to this individual.

Dietary:

yes yes yes yes yes yes

no no no no no no

Camphor/eucalyptus Chamomile Baking soda Witch hazel Arnica gel Sting stop

yes no After Bite 3 yes no Tea tree oil yes no Lavender yes no Rescue remedy yes no Calendula yes no Vitamin C

If you checked NO on any of the above, please list substitute here. ____________________________________________________________________________________

Does not eat red meat yes no Does not eat poultry Other: (describe) yes no

yes no yes no

Does not eat pork Does not eat seafood

yes no yes no

Does not eat eggs Does not eat dairy product

______________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________

Activities: Explain any restrictions to activity (e.g., what cannot be done, what adaptations or limitations are necessary) _______________________________________________________________

Do you have, or have you had, any of the following conditions or symptoms?

No Yes Condition

1- High 24Motion Blood Sickness Pressure

2- Heart 25SleepProblem Walking

3- Tuberculosis 26Broken Bones

4- Recent 27Neck Problem Exposure to TB

5- Active 28Back Problem Hepatitis

6- Seizure 29Shoulder Problem

7- Blood 30Knee Disorder Problem

8- Chronic 31Ankle Problem Cough

9- Recurrent 32Foot Problem Lung Infection

10- recent 33Asthmainjury, illness or infectious disease

11- chronic 34Diabetesor recurring illness/condition

12- Frequent 35Hypoglycemia ear infections

13- Heart 36Anorexia palpitations

14- Muscle 37BulimiaCramps

15- passing 38Cancer out during or after exercise

16- Dizzy 39Skin Problem during or (e.g., afteritching, exercize rash, acne)

17- Chest 40Circulation pain during Problem or after exercise

18- Diagnosed 41Bedwettingwith a heart murmur

19- Orthodontic 42Headaches appliance (brought to program)

20- Mononucleosis 43Head Injury in the past 12 months:

21- Diarrhea/constipation 44Heatstroke

22- Learning 45Hearing Impairment Disability

23- Other____________________ 46Vision Impairment

If YES to any of the items, please explain below, indicating the number of the condition. Include the date(s,) length, symptoms, restrictions, care required. Please use another paper if necessary. PART IV - CONDITIONS AND SYMPTOMS ITEM #

DETAILED DESCRIPTION

PART V - PERSONAL HISTORY Are you or have you been in counseling with a psychiatrist, psychologist, or other counselor within the past two years? YES NO If yes, but terminated - please state when terminated: Date ___/___/____ Reason for counseling (underline responses) Academic

Family Issue Depression Substance Abuse Career Divorce

Suicide

Other _____________________________

Name of most recent counselor __________________________________________ Telephone (____)___________________________________ Address ____________________________________________________________ City/State/Zip ______________________________________ Do we have permission to contact this counselor? Yes No Call us first. Use this space to provide any additional information about the participant’s behavior and physical, emotional, or mental health about which the Program leaders/Program Doctors should be aware

IMMUNIZATION HISTORY VACCINATIONS Please record immunization DATES (month and year) or attach a copy of immunization record from physician’s office. If you choose not to be immunized for family or religious reasons, please contact Footmarks for anRECEIVED Immunization Exemption Form. DATES DtaP or DTP (Diptheria, Tetanus, Pertussis) Date of most recent Varicella (Chickenpox) Date of most recent MMR (Measles, Mumps, Rubella)

Date of most recent

H. Influenza, type B Hepatitis A Hepatitis B Polio Other

List all Dates List all Dates List all Dates List all Dates List all Dates

PART VI - PHYSICIAN EXAM - to be completed by Physician. This form MUST be used. Footmarks House no. 393, sector 28, Noida, UP, INDIA.Ph:+91 9868126334, [email protected]

PLEASE Which of the NOTE: followingFootmarks diseases policies on Outdoor Program requires that a physical exam must have been completed before the start of your program, and by had? doctor on this form has theattested participant Measles SCREENING RECORD (for Program use only) Screened by ______________________________________________ Date Screened _____________ 1) Patient’s name--________________________________________________________________________________ 2) Date of last physical _____/______/______ day month year Meds Received ___________________________________________________________________________________________________________________________ Chicken pox Immediate health needs identified ____________________________________________________________________________________________________________ Observational Notes German ______________________________________________________________________________________-----______________________________ measles_____in. 4) Weight ______kgs. 3) Height _______ft. 5) Blood Pressure _______/_______ 6) Pulse Rate _____________

-

To the physician: ____________________________ is applying to attend ________________________________ during _________________. Mumps

7) Pulse Irregularities? NO If yes, please Footmarks describeprogram _________________________________________________________________________ participant or staff YES name dates PHYSICIAN SIGNATURE REQUIRED Hepatitis A

8) Applicant is under the care of a physician for the following conditions:

____________________________________________________________________ Hepatitis B _______________________________________________________________________________________________________________________________________________ Name of Physician (please print) ________________________ How long have you known the applicant? _______ Hepatitis C 9) Current Medications, dosage and frequency: (Please attach separate paper if necessary)

Address ______________________________________________________ telephone (____)_______________ __________________________________________________________________________________________________________________ PLEASENOTE: Participants taking psychotropic medications need to be on or off the drug 6 weeks prior to the program in order to allow sufficient time for the body to adjust.

Physician_s Signature _________________________________________________ Date _____/_____/_______ Yes No Medication(s) will be continued during Program session. Yes No Medication(s) will be completed before start of Program session.

10) Known Allergies: ____________________________________________________________________________________________________________________ 11) Any medically prescribed meal plan or dietary restrictions?___________________________________________________________________________________ 12) In the opinion of physician, this applicant IS IS NOT able to participate in an active camp or travel program. Abnormal health conditions? _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________

Restrictions? __________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________