CYIA Medical Questionnaire

Name

Age

Today's date

Medical Coverage for Applicant

Note: CYIA students are covered by accident insurance while at the CYIA training school.

Name of insurance company

Policy number

Date of last tetanus shot

Is the applicant subject to:

Asthma

Yes No

Hay Fever

Yes No

Epilepsy

Yes No

Food Allergies

Yes No

If yes, please list:

Allergies to Medications

Yes No

If yes, please list:

Other Allergies (flowers, grass, etc.)

Yes No

If yes, please list:

Has the applicant had:

Chicken Pox

Yes No

Measles

Yes No

Serious reaction to bee sting

Yes No

Does the applicant have:

Diabetes

Yes No

Hypoglycemia

Yes No

Is the applicant on a special diet?

Yes No

If so, what is it?

Has the applicant had any illness requiring a visit to the doctor or hospital in the last three months?

Yes No

If so, what was the health problem?

The nurse carries the following stock items. Please mark any you DO NOT want your child to receive. Asprin Aleve Ibuprofen Tylenol Tums Pepto-Bismol Throat lozenges (for sore throats and cough)

Allergy relief: Decongestants Cold syrups Loratadine Zyrtec Benadryl

Skin ointments: Neosporin Hydrocortisone Calamine Sunscreen Insect repellent

Please send prescription drugs in original container with proper dosage and usage inscribed. Mark student's name with permanent pen on all inhalers.

Please list any prescription drugs being brought by the applicant: (Name of medication, what it is for, and dosage and directions)

Note: If applicant has serious reactions to food or insect bites that require an Epi-Pen, please send with your student.

Liability Release

I hereby give permission for the above named minor to attend and participate in Christian Youth In Action. I release and hold harmless Child Evangelism Fellowship of Oregon Inc., its staff and volunteers, and the facilities used from responsibility and liability for any illness or injury that my child may sustain during this activity, provided the above have exercised reasonable caution and supervision concerning the safety of my child. In the event of an emergency, I hereby authorize an adult representative of this activity, as agent for me, to consent to any medical imaging or examination, medical, dental, or surgical diagnosis, treatment and hospital care advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of Oregon, either at a doctor's office, hospital, or any other medical facility. I expect that CEF authorities will notify me personally as soon as possible if there is an incident requiring the services of a physician for my child. I understand that if the applicant is sick for more than 36 hours, I will be responsible to arrange for transportation home.

Note: On electronic forms, your typed signature carries the same weight as your written signature.

Signature of applicant or parent/guardian (if applicant is under 18)

Phone

Address

If unable to notify me in case of emergency, please contact:

Name

Relationship to applicant

Emergency contact phone

CYIA Medical Questionnaire - Jackson

Description

CYIA Medical Questionnaire - Jackson

Description

Please Fix the Following