Medical Release and Health Record

The Health Department requires that we have this form completely filled out when you attend a youth conference.
The form is good for the program year (September - August).   A medical exam is not required to complete this form.

1. Name _________________________________________  Birthdate __________________



2. Address ______________________________________________________________

   City ___________________________  State ______ Zip _________ Phone ____________

3. Specific Permissions
   

   I give permission to the Powell House staff to give my child over-the-counter medications as necesary (e.g. Tylenol, antihistamine, et.) Parent or guardian signature ____________________________ Date_______	yes	no
   I give permission for my child to take homeopathic remedies. Parent or guardian signature ____________________________ Date_______	yes	no
   My child has an Epi-pen for the following reason: __________________________________



4. Persons to contact in an emergency
   
   Parent's name_________________________________ Phone_______________
   
   Parent's name_________________________________ Phone_______________

   If a parent is not available:

   Name_____________________________ Relation to youth ____________ Phone__________



5. In case the parents cannot be reached, I grant permission for the Powell House staff to provide and/or obtain emergency treatment for this youth and to act "in Locus Parentis." I also grant permission for off-campus trips as scheduled and supervised by Powell House staff.

   Signature of parent/ guardian _____________________________ Date___________

6. If my child has to be transported to a hospital, I prefer that they go to:
   
   
   1.Columbia Memorial-Hudson ______  2. Albany _______ 3. Pittsfield, MA ________
The Chatham ambulance normally goes to Hudson. They may go to the others for your conveniece.


7. Date of last physical eaxm ___________ Physician's name ____________________________
   
   Address:_________________________________ Phone ______________________



8. General Health?   Excellent______   Good______  Poor_____



9. Any recent illness, diseases, or physical impairments? Please explain:

   ___________________________________________________________________

   ____________________________________________________________________

10. Date of last tetanus immunization or booster shot ____________________
    
    Please list the last dates for the following immunizations:
    
    DPT __________ Measles________ Rubella______ Polio______ Mumps_______



11. Please list any allergies (even minor ones). Explain severity, medication and emergency procedures:
    
    Foods:
    
    Others:

12. Please list all medications (include their dose and frequency) that this youth uses regularly.

    _______________________________________________________________________

    _______________________________________________________________________

13. Are there other things that the youth directors should know about? (e.g. strong fears, bed wetting, recent changes in living situation, sleep walking)

    _______________________________________________________________________

    _______________________________________________________________________

14. Health Insurance Info:

    Carrier _________________________ Type ______________  ID#________________________