Upward Bound Program

Medical History Form

Name of student: Last, First MI *

Date of Birth: *

Parent/Guardian Name: Last, First MI *

Address: Street, City, Sate, Zip Code *

Phone Number: *

Emergency Number: *

Doctor: *

Address: Street, City, Sate, Zip Code *

Phone Number: *

Medicaid Number:

Other Medical Insurance #:

Company:

Illnesses, disorders and/or allergies: *

List any operations: *

List any severe injuries: *

Numbers of days lost due to illness during the past year: *

List any acute or chronic medical problems: *

*Note: If your child is taking medication that will be administered during the Summer Program's functions, we will need a Doctor's note in case your child needs treatment if an injury or accident should occur.

Is student receiving any medication: *

If yes, please list dosage and diagnosis:

How will the student administer medication?

If other please specify with detail:

Is there a specific requirement for storing medication brought by your student?

List any dietary restrictions

Parent/Guardian Signature: *

Signature Type: SMS Start Over

After validation, the cell phone number will become part of the electronic signature.

Cell Phone Number:

Enter characters above to send message.

Date: *