The Roberto Ocasio Latin Jazz camp STUDENT HEALTH INFORMATION
Email address *
*PLEASE NOTE: A COPY OF YOUR MEDICAL INSURANCE CARD MUST BE ATTACHED TO THIS FORM. IF STUDENT DOES NOT HAVE MEDICAL COVERAGE, PLEASE CONTACT BEV MONTIE, 440.572.2048 PRIOR TO CAMP.
Please have a digital version of the card ready for upload prior to starting the form. It can be a .jpg, .png, .pdf or other standard image file.
Student Name *
Age *
Birthdate *
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Gender *
Custodial Parent/Guardian Name *
City *
State *
Zip Code *
Phone (Primary) *
Phone (Additional)
Other Parent/Guardian or Emergency Contact *
Address *
City *
State *
Zip Code *
Phone (Primary) *
Phone (Alternate)
If not available in an emergency, please notify: *
Relationship: *
Address *
City *
State *
Zip Code *
Do you carry medical/hospital insurance? *
If you answered "Yes" above - Please provide the name of the Medical Insurance Company and Policy Number *
Please upload a copy of the insurance card *
Required
For your student’s safety, it is imperative that we know of any medical concerns and medications. This information will be kept confidential and shared only under warranted circumstances with a physician or health-care provider, Cleveland emergency responders, Case Western Reserve University Security Staff (or Camp Staff, as required).
Please list over-the-counter or current prescription drugs (including an epi pen) which the student will require during Camp. The Roberto Ocasio Camp Staff will not dispense any medications to students; taking prescriptions and medications must be the responsibility of the student and parent/guardian. *
Date of most recent tetanus shot *
MM
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DD
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YYYY
Health History (to be kept on file in the event it is needed by a physician or health-care provider)
Has the student...
had any recent injury, illness or infectious diseases? *
have a chronic or recurring illness/condition? *
ever been hospitalized? *
recently?
ever had surgery? *
recently?
have frequent headaches? *
ever had any serious injuries? *
recently?
wear glasses, contacts or protective eyewear? *
ever had frequent ear infections? *
ever been dizzy or passed out during or after exercise? *
ever had seizures or other epileptic symptoms? *
ever had hypertension? *
ever had heart defect or disease? *
ever had back trouble? *
ever had problems with joints(knees, ankles, etc)? *
have an orthodontic appliance which will be brought to camp? *
have any skin problems (itching, rash, acne, etc)? *
have diabetes? *
have asthma? *
had mononucleosis within the past 12 months? *
had problems with diarrhea/constipation? *
if female, have an abnormal menstrual history?
have an eating disorder? *
had emotional difficulties (including anxiety, fears/phobias) which required professional help? *
have any physical challenges? *
have any sleep disorders or a tendency for sleepwalking? *
have any allergies? (seafood, peanuts, other foods, insect stings, medications, etc) *
If "yes" above, please specify...
Does the student require an epi pen in his possession for emergencies? *
have dietary limitations or requirements? *
have any activity restrictions? *
have any other special requirements or medical conditions? *
If "yes" above, please explain in detail.
Preferred Physician *
Physician Phone *
Preferred Dentist *
Dentist Phone *
Note: By submission and receipt of a student’s parent-authorized application to attend Camp, it is assumed that the student is of a maturity level to be accountable for any limitations, restrictions, or special conditions (whether or not listed on this form or communicated to the Camp Director/Staff or The Roberto Ocasio Foundation). Every reasonable effort will be made by the Camp Director and Staff to supervise and provide for students’ special circumstances; however, the ultimate responsibility rests with the students to address concerns and abide by parent and/or medical instructions.
PARENT OR GUARDIAN CONSENT
1) The information provided on this form is correct and complete to the best of my knowledge, and my child has my permission to engage in all Ocasio Camp activities except as noted. This completed confidential form may be photocopied and taken on fieldtrips away from the Ocasio Camp and CWRU Campus.

2) I hereby authorize the Ocasio Camp Director or Case Western Reserve University Security Staff to act on my behalf to provide first aid for my child, if needed according to their best judgment. In the event that I cannot be reached in an emergency, I hereby give permission to the physician, medical personnel and hospital or medical center selected by the Camp director or Case Western Reserve University Security Staff to secure and administer medications and treatment (including hospitalization), to arrange related transportation, order necessary x-rays and tests, provide anesthesia, or surgery for my child.

3) I hereby authorize the release of any records that the physician, hospital or medical facility at their discretion may deem necessary for treatment of my child, including information contained in this form.

4) I hereby authorize release of related medical records for insurance purposes and payment of medical benefits to the designated physician, provider or hospital for services described herein. I will assume responsibility for fees incurred for such services that are not covered by insurance.

Electronic Signatures. Each party agrees that the electronic signatures of the parties included in this Agreement are intended to authenticate this writing and to have the same force and effect as manual signatures.

Electronic Signature means any electronic sound, symbol, or process attached to or logically associated with a record and executed and adopted by a party with the intent to sign such record[, including facsimile or email electronic signatures] pursuant to the Ohio Uniform Electronic Transactions Act (R.C. 1306.01 et seq.) as amended from time to time.
Parent or Guardian Signature
Insurance Certificate Holder Signature
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