MNV- TNTT Health History Form

This form MUST be FILLED before any participation in the Organization/Camp. Name: ________________________________________________________________________________ Birth date (DD/MM/YY):______/_______/_______ Age: ________ Sex: Male/ Female Street Address_____________________________ City: ________________ State_____ Zip Code_______ Home Phone: ( ) Work Phone: ( ) _ Cell Phone: ( ) ) ____ _

Emergency Contact: _____________________________ Emergency Phone: ( __Asthma __Heart Defect/Disease __Recent Hospitalization __Currently under doctors care __Seizures __Diabetes

Medical Information (please check all that apply) __ Head Lice __Measles __Bedwetting __German Measles __ Sleepwalking __Other Diseases / Conditions __Tuberculosis _________________________ __Chicken Pox _________________________ __ADD/ADHD _________________________

For each check, please explain: __________________________________________________________ ____________________________________________________________________________________ Please note: If you has any following conditions you cannot attend camp until a physician has given authorization: Asthma, Heart Defect/Disease, Seizures, or Diabetes. Has you ever been stung by a bee before? If so, please explain how you reacted physically: __ _____________________________________________________________________________________ Are your Immunization Records up to date? _______________________ Current Medications to be continued at camp (dosage & frequency, may attach in the back if needed) _____________________________________________________________________________________ (All prescription medications must be in the original container. We cannot vary from instructions on container) Any known allergies? ___________________________________________________________________ Any Reason to restrict activity? ___________________________________________________________ Non-Prescription Medications: Please initial to authorize the following medications to be administered as needed: ____Tylenol ____Benadryl _____Tums
Waiver of Liability Signature required for camp attendance. I, the participant, who attends in the activities sponsored by The Vietnamese Eucharistic Youth Society (VEYS) of Immaculate Heart of Mary Church; I hereby voluntarily and knowingly assume all risks and dangers inherent and incidental to the activities of the program. I will not hold the VEYS liable for any injuries incurred during the program whether caused by equipment or the acts of omission by others excepting the damage or injury solely caused by the willful misconduct or negligence of the VEYS personnel. I do hereby authorize the VEYS as agent for me, to consent with any x-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment, and hospital care which are deemed advisable by, and are rendered under general or special supervision of, any physician and surgeon licensed under the State of Nebraska. I understand that the VEYS is not responsible for the costs incurred for the medical care.

Signature of participant ________________________________________ Date: _____________