FIA Participant Medical Form 2023

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FIA Summer Camp Medical Form

Please note: Due to Covid-19, all participating children are required to bring face masks, hand sanitizer, and a pack of hand wipes. FIA programs often consist of vigorous exercise and activity. If you know of any reason why your child should not participate in these activities, please advise and note on this form. We will adhere to social distancing requirements. All children and staff will be temperature checked upon arrival. Should the temperature reading be 100.4 or above, AND/OR if your child is showing any signs of illness, they will not be permitted to attend the program. For everyone's health and safety, we cannot make exceptions, and we thank you in advance for not asking our staff to do so if your child is not permitted to enter the program site. There is a short questionnaire regarding COVID exposure as well upon arrival. Initials Required. *

PLEASE NOTE: IMMUNIZATION RECORDS MUST BE SUBMITTED IN ADDITION TO THIS FORM.

Parent/Guardian Name: *

Parent/Guardian Telephone: *

Physician: *

Physician Telephone: *

Name of Health Insurance Carrier: *

Group No: *

Agreement No. (if any) *

Other: *

Child/Participant's Current Medical Condition: *

Date of Last Physical: *

YYYY

Participant Name: *

Date of Last Tetanus Shot: *

YYYY

List of Prescription and Non-Prescription Medications Child/Participant is Taking: *

Allergies and Drug Sensitivity (List and describe effects): *

Have you ever been told your child has/had one of the following? *

Lung Disorder

Covid-19

High Blood Pressure

Heart Trouble

Nervous Disorder

Asthma

Hepatitis

Malaria

Digestive Track Disorder/Disease

Neurological Disorder/Disease

Heart Disorder/Disease

Back/Spine Disorder/Disease

Blood Disorder/Disease

Vision Disorder

Hearing Impairment

Life Threatening Disorder/Disease

Physical Deformity

Contagious Disorder

ADD/ADHD

None of the above

Other

Required

Has your child or anyone in your home had Covid-19 or been exposed to Covid-19? Please list all persons exposed and dates of exposure. *

Please share results and date of Covid-19 testing, if any. *

Has your child ever been treated by a physician or been disabled or hospitalized in the past year or two years? Describe. *

Has your child been advised to have a surgical operation within the last five years? Please explain. *

Family History (List pertinent medical problems of parents/guardians): *

Does your child have an IEP? *

Yes

Required

If your child has an IEP, please state diagnosis or list learning and thinking differences. If none, please state N/A *

Please list any other medical information in space below. *

FIRST AID/EMERGENCY MEDICAL TREATMENT: the parent/guardian of the child listed above, give permission for Faith in Action, Supplemental Support Services Program, Performing Arts Camp, Burlington County Mentoring, etc., into whose care said minor child has been entrusted, to seek emergency medical care for my child at a nearby hospital or medical facility, in the event of illness or injury, I, the parent/guardian, will assume all financial responsibility for such emergency medical treatment. I also give permission for the attending physician and medical personnel to administer needed medical treatment, including surgery, andI understand that I am responsible for any medical bill. By completing and submitting this form, you agree to the terms and conditions. Please type your initials below. *

YES. I Agree. *

Yes, I agree. - Thank you. Your answers will be saved.

Please type your full name *

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