CYIA Medical Questionnaire - Umpqua

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Medical Coverage for Applicant

Note: CYIA students are covered by accident insurance while at the CYIA training school.
 
 
 
Is the applicant subject to:
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Please select one option.
 
Please select one option.
 
Has the applicant had:
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Does the applicant have:
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Please select all that apply.
Please select all that apply.
Please select all that apply.
Please send prescription drugs in original container with proper dosage and usage inscribed. Mark student's name with permanent pen on all inhalers.
 
 
 
 
Note: If applicant has serious reactions to food or insect bites that require an Epi-Pen, please send with your student.

I understand that if the applicant is sick over 36 hours, I will have to arrange for other transportation home. In case of medical emergency, I hereby give permission to the physician selected by the training school nurse to secure proper treatment for me or my child as named on this form. (You will be notified as soon as possible in case of serious injury or illness.)

Note: On electronic forms, your typed signature carries the same weight as your written signature.
 
 
 
 
If unable to notify me in case of emergency, please contact:
 
 
 

Description

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