Health History

TO BE FILLED OUT BY PARENT

Participant Name _____________________________________________________________________

Date of Birth _______________________ Male ___ Female ___ SS# ___________________________

Parent/Guardian ___________________________________ Phone #___________________________

Medical Insurance information

Please indicate the policy and group # information that the participant is covered by:

______________________________________________________________________

If not available in an emergency, please notify:

Name/Relation ______________________________________Phone #___________________________

PLEASE EXPLAIN ALL AFFIRMATIVE ANSWERS:

A) Has your son/daughter:

Ever been hospitalized? __ No __ Yes - ___________________________________________________

Suffered from: __Heart Condition __Cancer __Cerebral Accidents __Nervous Disorders __Other

____________________________________________________________________________________

Required any operations for any condition/issue? __ No __ Yes - ________________________________

Ever had an injury as a result of an accident? __ No __ Yes -___________________________________

B) Does your son/daughter suffer from any form of disability? __ No __ Yes -_______________________

C) Any specific activities to be restricted? __ No __ Yes -______________________________________

D) Any specific dietary restrictions? __ No __ Yes -___________________________________________

E) Does your child require any medications? __ No __ Yes -____________________________________

F) Any allergies? Please Explain.  ___________________ ____________________________________

Is your child under any psychological treatment or counseling? Although we require information regarding treatment in counseling, this in no way means that your son/daughter will not be accepted to the program. This information gives us the ability to deal with any situations that may arise on the program. Inaccurate information inevitably harms the participant. We require honest and factual information to appropriately determine your child’s needs. Please explain.

__________________________________________________________________________________________________________________________________

This health history is correct as far as I know, and the person herein described has permission to engage in all prescribed activities except as noted by the examining physician and me. In the event that I cannot be reached in an EMERGENCY, I hereby give permission to the physician selected by the Oranim Educational Initiatives summer program to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above.

_______________________________ _______________

Parent Signature Date