Health History
Please select one
Name and date of youth hunt/activity
Your answer
Name (Last, First, M.I.) *
Your answer
Address
Your answer
Date of Birth *
MM
/
DD
/
YYYY
1. Parent/Guardian
Your answer
Contact Number
Your answer
2. Parent/Guardian
Your answer
Contact Number
Your answer
Relative/trusted person to be contacted in case parent/guardian cannot be reached in an emergency:
1.Name(First, Last)
Your answer
Relation to Youth
Your answer
Contact Number
Your answer
2. Name(First, Last)
Your answer
Relation to Youth
Your answer
Contact Number
Your answer
Are you physically disabled?
If yes, please explain:
Your answer
Special medications are being sent with the above minor to meet his/her needs during the youth hunt/activity.
If yes, list name of drug(s) and/or medication along with name and phone number of prescribing physician dosage, consumption rate and interval:
Your answer
Special dietary needs or food allergies
Your answer
Health History: (Please check any of the following that apply.)
Any operations/serious injuries that would inhibit participation
Your answer
Family Physician
Your answer
Phone Number
Your answer
Medical Insurance
Your answer
Policy Number
Your answer
Are your immunizations current?
Date of last Tetanus shot
Your answer
*If you have a special dietary need/food allergy, it is your responsibility to contact HFY prior to the hunt/activity so we can make proper accommodations.
Sign (Parent/Guardian)
Your answer
Date
MM
/
DD
/
YYYY
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