2024 ALABGS Health Form

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To the Parents(s) or Legal Guardian:

If your daughter or ward will be under the age of 18 while at the University of Wisconsin Oshkosh, it is American Legion Auxiliary Badger Girls State (ALABGS) policy to secure your consent for medication distribution and for the use of medical devices.

Medications are to be in the original container, the name of the medication, the dosage, the frequency of administration and the route of administration should be indicated on the label. The label should also have the name of the prescribing physician, the prescription number, date prescribed, possible adverse reaction, the specific conditions when contact should be made with the physician and other special instructions as needed.
Place any prescription drugs or medications in a zip lock bag identified with your name. Bring only the amount you'll need for the amount of days at ALABGS session.

All medications brought by a citizen who is under 18 years of age shall be kept in a locked unit and shall be administered by one of our Nursing staff. A citizen may carry bee sting medications, epipen, inhalers, an insulin syringe or other medication or device used in the event of life threatening situations. Any deviation from this will be up to the Head Nurse.

Part 1: Please fill out questions completely *

No prescription medication will be brought to ALABGS

I agree to have the prescription medication or medical device administered by the ALABGS Health Staff. However, a limited amount of prescription medication for life threatening conditions may be carried by the daughter/ward (i.e. bee sting kits, inhalers, etc)

Part 2: Confidential Health History

Please fill out completely

Delegate's First Name *

Delegate's Last Name *

Delegate's Date of Birth *

YYYY

Name of Delegate's High School *

Home Address: *

City *

State *

Zip Code *

Parent/Guardian First Name *

Parent/Guardian Last Name *

Is Your Address Different From Above? *

Yes

If the Parent/Guardian address is different, please list what it is below

Relationship to delegate *

Phone number where you can be reached: *

Secondary Phone Number (if available)

Alternate Contact #1 (In the event that the Parent/Guardian cannot be contacted in an emergency).

First Name of Emergency Contact #1 *

Last Name of Emergency Contact #1 *

Phone Number *

Relationship to Delegate *

Alternate Contact #2 (In the event that the Parent/Guardian cannot be contacted in an emergency).

First Name of Emergency Contact #2 *

Last Name of Emergency Contact #2 *

Phone Number *

Relationship to Delegate *

Physician and Insurance Information

Name of Physician *

Phone Number of Physician *

Insurance Company *

Policy Holder Name *

Group Number *

Subscriber or Policy Number *

Immunization Record

Please Check all Immunizations the Delegate has Received *

MMR (Measles, Mumps, Rubella)- DOSE 1 (Immunization at age 1)

MMR (Measles, Mumps, Rubella)- DOSE 2

Tetanus- Diphtheria

COVID-19 Johnson & Johnson

COVID-19 Moderna or Pfizer Dose #1

COVID-19 Moderna or Pfizer Dose #2

COVID-19 Booster Shot

Other:

Required

If you checked "Yes" to Tetanus-Diphtheria, please put the year of last Tetanus Boost, or put N/A *

Hospitalizations and Physicals

Has the delegate ever had major surgery or been hospitalized? *

Yes

Please explain any significant operations, accidents or illnesses, and last major medical attention and reason. If there is none, please write N/A *

Does the delegate have any physical condition(s) requiring special considerations? If so, please explain. If not, please write N/A *

Date of Delegate's last physical exam *

YYYY

Allergies

Please mark any allergic reactions to the following (food will be in next section): *

Penicillin

Other Antibiotics (please list below under "other")

Insect Bites/Stings

None

Other:

Required

Please list any significant food allergies. If there are any, please contact Executive Director Delores Woolf to discuss meal options- her contact information is listed on the ALABGS website. If there are none, please write N/A *

Current or Past Medical Conditions

Please mark if the delegate had or is presently experiencing any of the following: *

Allergies

Asthma

Bleeding Disorder

Cancer

Colitis

Diabetes

Epilepsy/Seizures/Blackouts

Heart Disease

Hernia

High Blood Pressure

Joint Injury/Surgery

Kidney Disease

Menstrual Difficulties

Mental/Emotional Problems

Neck/Back Pain or Injury

Rheumatic Fever

Tuberculosis

Ulcer

None of the Above

Required

Prescription Medications

Does the Delegate take prescription medication on a regular basis? *

Yes

Please list the prescription medications the delegate takes. If they do not take any, please write in N/A *

Parent/Guardian Signatures

 If your daughter or ward will be under the age of 18 years while at American Legion Auxiliary Badger Girls State, it is our policy to secure your consent for medical treatment.
 By signing below you are giving your consent in advance for medical treatment at an appropriate medical facility in case of illness or injury. (Mercy Medical Center or Aurora Medical Group)
 By signing below you are stating that you are aware of and accept the risk inherent in the program activity.
 By signing below you agree to hold harmless and identify the Board of Regents of the University of Wisconsin System and the University of Wisconsin-Oshkosh, their officers, employees and agents, from any and all liability, loss, damages, or expenses which are sustained, or required arising out of the actions of your dependent in the course of the American Legion Auxiliary Badger Girls State session.

By typing your (the Parent/Guardian) name below, you agree that all of the information above is correct to the best of your knowledge and agree to the statements above: *

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