2020 Summer Camp Health Form
Email address *
CONTACT INFORMATION
Student's First Name *
Your answer
Student's Last Name *
Your answer
Student's Date of Birth *
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DD
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Grade for 2020-2021 *
Your answer
Parent/Guardian #1 First Name *
Your answer
Parent/Guardian #1 Last Name *
Your answer
Phone Parent/Guardian #1: *
Your answer
Parent/Guardian #2 First Name
Your answer
Parent/Guardian #2 Last Name
Your answer
Phone Parent/Guardian #2:
Your answer
If you listed 2 parents/guardians, are both legally responsible for the student?
If you answered NO to the prior question, please name here the person who is legally responsible for the student:
Please list first and last name and relationship to student.
Your answer
EMERGENCY CONTACTS AND HEALTH CONDITIONS
If the student needs immediate medical attention and we are unable to reach the student's legal guardian/s, we will try to contact the people listed as emergency contacts.

Please Note: The Emergency Treatment for Minors Act (Minnesota Statue 144.344) allows schools to make emergency decisions about sensitive health issues and concerns and physicians to provide immediate care while parents are being contacted.
Emergency Contact #1 First Name *
Your answer
Emergency Contact #1 Last Name *
Your answer
Phone Emergency Contact #1: *
Your answer
Emergency Contact #2 First Name *
Your answer
Emergency Contact #2 Last Name *
Your answer
Phone Emergency Contact #2: *
Your answer
EMERGENCY HEALTH CONDITIONS *
Does your child have a health condition that could result in an emergency? ( Example: allergies, asthma, seizures)
If you answered yes, please describe:
Your answer
IN CASE OF EMERGENCY, HOSPITAL PREFERENCE
Your answer
MEDICATION AUTHORIZATION *
Please authorize any emergency medication that will need to be kept in the health office during our summer program. Prescribed medications must come in the original pharmacy container with the doctor's name and order listed. All other medications should be taken at home.
Medication #1:
Please list medication name and instructions for use (include: dose, frequency and under what circumstances it should be given):
Your answer
Medication #2:
Please list medication name and instructions for use (include: dose, frequency and under what circumstances it should be given):
Your answer
I give permission to trained staff to administer this medication according to the above instructions. I release school personnel from any liability in the administration of this medication.
Middle School Student--AUTHORIZATION TO CARRY
Emergency inhalers or epinephrine may be self-carried by students in 5th through 8th grade. All other medications must be kept in the school health office. My student will self-carry an inhaler and/or epinephrine as listed above:
Please share any additional information that will assist us in making your child's summer experience safe and successful.
Your answer
Are your child's immunizations (vaccinations) current? *
If you answered "No" to immunization, please explain.
Your answer
PUBLICITY, PHOTO, FILM AND VIDEO RELEASE
Yinghua makes a concentrated effort to promote Chinese language and culture as well as the positive activities, honors and work of our staff and students. This includes developing our own publications and working with newspapers, magazines, radio, television and social networks. These publications include information, likenesses, and images which may appear on the school website as well as in other publications. There may be opportunities for students to be interviewed and/or photographed and identified by name. However, we understand that some may request not to be identified. Please answer the questions below to inform us of your wishes regarding publicity. Please note, however, that your child’s image or likeness may appear in occasional candid photos without any type of identification and the use of these candid photos is permissible without this release. *
A copy of your responses will be emailed to the address you provided.
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