ALABGS Health Form
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 *
Part 2: Confidential Health History
Please fill out completely
Delegate's First Name *
Your answer
Delegate's Last Name *
Your answer
Delegate's Date of Birth *
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DD
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Name of Delegate's High School *
Your answer
Home Address: *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Parent/Guardian First Name *
Your answer
Parent/Guardian Last Name *
Your answer
Is Your Address Different From Above? *
If the Parent/Guardian address is different, please list what it is below
Your answer
Relationship to delegate *
Your answer
Phone number where you can be reached: *
Your answer
Secondary Phone Number (if available)
Your answer
Alternate Contact #1 (In the event that the Parent/Guardian cannot be contacted in an emergency).
First Name of Emergency Contact #1 *
Your answer
Last Name of Emergency Contact #1 *
Your answer
Phone Number *
Your answer
Relationship to Delegate *
Your answer
Alternate Contact #2 (In the event that the Parent/Guardian cannot be contacted in an emergency).
First Name of Emergency Contact #2 *
Your answer
Last Name of Emergency Contact #2 *
Your answer
Phone Number *
Your answer
Relationship to Delegate *
Your answer
Physician and Insurance Information
Name of Physician *
Your answer
Phone Number of Physician *
Your answer
Insurance Company *
Your answer
Policy Holder Name *
Your answer
Group Number *
Your answer
Subscriber or Policy Number *
Your answer
Immunization Record
Please Check all Immunizations the Delegate has Received *
Required
If you checked "Yes" to Tetanus-Diphtheria, please put the year of last Tetanus Boost, or put N/A *
Your answer
Hospitalizations and Physicals
Has the delegate ever had major surgery or been hospitalized? *
Please explain any significant operations, accidents or illnesses, and last major medical attention and reason. If there is none, please write N/A *
Your answer
Does the delegate have any physical condition(s) requiring special considerations? If so, please explain. If not, please write N/A *
Your answer
Date of Delegate's last physical exam *
MM
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DD
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YYYY
Allergies
Please mark any allergic reactions to the following (food will be in next section): *
Required
Please list any significant food allergies. If there are any, please contact Executive Director Delores Woolf to discuss meal options- her number is on the ALABGS website. If there are none, please write N/A *
Your answer
Current or Past Medical Conditions
Please mark if the delegate had or is presently experiencing any of the following: *
Required
Prescription Medications
Does the Delegate take prescription medication on a regular basis? *
Please list the prescription medications the delegate takes. If they do not take any, please write in N/A *
Your answer
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: *
Your answer
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