SUMMER STAGE Health History Form

HEALTH HISTORY FORM

CLOCKTOWER PLAYERS SUMMER STAGE

STUDENT HEALTH HISTORY

STUDENT Name ______________________________________

PARENT Names __________________________________________

Home Phone ______________Work Phone ______________  Cell Phone ________________

IN CASE OF EMERGENCY, IF PARENT CANNOT BE REACHED, CONTACT:

1. _______________________________   _________________  ________________

NAME                                                          DAY PHONE             CELL PHONE

2. _______________________________  _________________  ________________

NAME                                                         DAY PHONE             CELL PHONE

Name of Child's Doctor ________________________  Doctor's PHONE ___________________

Name of Child's Dentist ________________________  Dentist's PHONE __________________

The following information will be released to the staff of Clocktower Players, as well as any emergency medical personnel, so that any necessary and/or appropriate accommodations can be made to ensure the safety of your child and enable him to successfully participate in SUMMER STAGE. Please indicate health problems that may require any accommodations:

__ speech impairment ___visual impairment ___hearing impairment __neurological impairment

__ behavioral/emotional disorder  __anxiety disorder____ seizure disorder  ___bleeding/clotting disorder

____cardiac condition   __learning disability   _____ diabetes   ____other (specify)_________________

allergies:

____ food (specify) _________________________________________
____ penicillin
 ___  insect bites or stings
____ medication  (specify) __________________________________

___   asthma 

If your child has asthma does he/she have an inhaler or other medication that should be administered?

If so, please include a separate letter with name and dosage as well as conditions under which it should be administered.

If your child will be taking medication while at SUMMER STAGE please include a separate letter with name and dosage, as well as conditions and/or times under which it should be administered.

Does your child have any chronic or recurring illness we should be aware of ? ___________________

Any specific activities to be limited or encouraged by physician's advice? _____________________

_________________________________________________________________________________

Any dietary restrictions? _____Yes   _____ No

If Yes, please specify: _____________________________________________________________