Section 1 of 4
2018-2019 GOYA MEDICAL INFORMATION FORM (One form per child, please)
Saints Constantine and Helen Greek Orthodox Church of Washington, DC
GOYAn Name:
GOYAn Name:
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GOYAn Date of Birth
GOYAn Date of Birth
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Pediatrician's Name
Pediatrician's Name
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Pediatrician's number
Pediatrician's number
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Dentist Name
Dentist Name
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Dentist number:
Dentist number:
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Preferred Hospital
Preferred Hospital
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Emergency Contact #1
Emergency Contact #1
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Relationship to GOYAn
Relationship to GOYAn
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Contact number
Contact number
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Emergency Contact #2
Emergency Contact #2
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Relationship to GOYAn
Relationship to GOYAn
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Contact number
Contact number
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Section 2 of 4
Additional Health Information
List all Allergies
List all Allergies
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Do any of the allergies listed above require an Epi-Pen?
Do any of the allergies listed above require an Epi-Pen?
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1.
Yes
2.
No
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If you answered yes above, please tell us what allergy required use of the Epi-Pen.
If you answered yes above, please tell us what allergy required use of the Epi-Pen.
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Medical History: please list all pertinent medical history that may interfere with the participants ability to partake in GOYA activities, or that may arise in the environment (to include mental health history, if applicable) none
Medical History: please list all pertinent medical history that may interfere with the participants ability to partake in GOYA activities, or that may arise in the environment (to include mental health history, if applicable) none
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Special Precautions: please list any special precautions. That should be observed regarding this participant to include any restrictions in the activities in which this participant may partake. Additionally, please provide any miscellaneous information that you believe the GOYA Liaisons should be aware of. none
Special Precautions: please list any special precautions. That should be observed regarding this participant to include any restrictions in the activities in which this participant may partake. Additionally, please provide any miscellaneous information that you believe the GOYA Liaisons should be aware of. none
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Scheduled Medications: please list al medications (prescribed and over the counter) that are taken on a regular basis by the participant (with the exception of non-prescription. acne medication). Also, please indicate the times the medication is to be given and the dosages of each medication. none
Scheduled Medications: please list al medications (prescribed and over the counter) that are taken on a regular basis by the participant (with the exception of non-prescription. acne medication). Also, please indicate the times the medication is to be given and the dosages of each medication. none
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As Needed Medications (PRN): please list all medications that are to be taken as needed by the participant. Such medications may include Acetaminophen (Tylenol), Ibuprofen (Motrin), Antacids (Tums), Antihistamines (Benadryl), allergy medication, etc. Please keep in mind, the church staff will have several basic PRN medications that may be administered, however, please provide any PRN medications that you anticipate the participant needing to church staff at drop-off to ensure an adequate supply. tylenold, motrin, advil
As Needed Medications (PRN): please list all medications that are to be taken as needed by the participant. Such medications may include Acetaminophen (Tylenol), Ibuprofen (Motrin), Antacids (Tums), Antihistamines (Benadryl), allergy medication, etc. Please keep in mind, the church staff will have several basic PRN medications that may be administered, however, please provide any PRN medications that you anticipate the participant needing to church staff at drop-off to ensure an adequate supply. tylenold, motrin, advil
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Please list anything else you feel that we need to know.
Please list anything else you feel that we need to know.
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Section 3 of 4
Be advised, ALL medications (with the exception of epinephrine auto injectors and rescue inhalers) must be turned in to church staff before getting on a bus for a GOYA event. Medications will then be administered to each participant in accordance with the above instructions by a GOYA Liaison.
Section 4 of 4
**** Please submit a HARDCOPY of the FRONT and BACK of the Family Health Insurance card to a GOYA Liaison.****
By signing below, I acknowledge that all information provided above is current and accurate. If anything changes throughout the 2018-2019 year, I will update the form. Irene Sideris
By signing below, I acknowledge that all information provided above is current and accurate. If anything changes throughout the 2018-2019 year, I will update the form. Irene Sideris
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10/16/18
10/16/18
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