LEWISBURG SCHOOL DISTRICT: SKI CLUB HEALTH HISTORY FORM
A copy of this form must be on file for each student skier/snowboarder and need be submitted only once. This information will only be shared with authorized chaperones and emergency personnel if necessary.
Email address *
Students last name *
Your answer
Students first name *
Your answer
Student's grade *
Birth Date *
Your answer
Student's Address *
Your answer
Student's Cell Phone *
Your answer
Parent/Guardian Name(s) *
Your answer
Parent/Guardian Home Address *
Your answer
Parent/Guardian Home Phone *
Your answer
Parent/Guardian Cell Phone Numbers *
Your answer
Other phone number where Parent/Guardian can be reached during Ski Club trips *
Your answer
If parent/guardian is not available in emergency, notify: (include name, cell number and relationship to skier/snowboarder) *
Your answer
Does skier/snowboarder have any known allergies? *
Required
Allergies to medications: *
Your answer
Food Allergies: *
Your answer
Other Allergies: *
Your answer
Health History: Check any that apply *
Required
Is skier/snowboarder presently taking or using any type of medication(s) or drug(s)? If yes, please specify. *
Required
If yes, please specify.
Your answer
Is skier/snowboarder presently under a physician's care? *
Required
If yes, please specify.
Your answer
Is the skier/snowboarder current on all immunizations needed for school? *
Date of last Tetanus Inoculation: *
Your answer
Head and Neck Conditions: Check all that apply *
Required
Dates of Injuries to Head and Neck and Explanation of Injuries
Your answer
Orthopedic Conditions: Has the skier/snowboarder ever had an injury or surgery to any of the following? Check all that apply *
Required
Please explain any of the injuries noted in the previous question.
Your answer
Does the skier/snowboarder have any problems not previously mentioned that you feel the medical personnel should know about in the event of an injury?
Your answer
Name and Phone Number of Family Doctor *
Your answer
Name and Phone Number of Family Dentist *
Your answer
Family Medical Insurance *
Insurance Information: Name of insured *
Your answer
Health Insurance Provider *
Your answer
Health Insurance Group Number (if applicable) *
Your answer
Health Insurance Policy Number *
Your answer
Health Insurance Phone Number *
Your answer
Permission to Treat: I, (We) the parent/guardian(s), a student of Lewisburg Area School District, give permission for a physician or dentist to treat my/our son/daughter, because of an emergency situation caused by injury or illness while he/she is participating in a Lewisburg School District Ski Club activity and I/We am/are not there to authorize treatment. Please sign below. *
Your answer
Confirmation of Electronic Registration: I, (We), the parent/guardian(s) a student in the Lewisburg Area School District do certify that I personally filled out the online registration and gave my permission through my electronic signature for my student to attend the school trips of their choosing. Please sign below. *
Your answer
A copy of your responses will be emailed to the address you provided.
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