NAP Health Form

NATURALIST ASSISTANT PROGRAM HEALTH INFORMATION Teen’s Name & Birth Date:____________________________________________ Parent or Guardian Name: ____________________________________________ Home Address: ___________________________________________________________ ________________________________________________________________________ Phone: (h)____________________________ (w)___________________________ Parent or Guardian Name(if different than above): _____________________________ Home Address: ___________________________________________________________ ________________________________________________________________________ Phone: (h)____________________________ (w)___________________________ Emergency Contact Name: __________________________________________________________________ Phone: (h)____________________________ (w)___________________________ Please list the individuals (and their relationship to your teen) that will be allowed to pick up your teen from NAP events: ______________________________________________ ________________________________________________________________________ Is there anyone who will not be able to pick up your teen? No or Yes, if yes, who? _____ ________________________________________________________________________ Medical Authorization and Statement of Release (parent or guardian signature required) In consideration of the acceptance of this form, I hereby agree to release and forever hold harmless the Athens-Clarke County Government and/or Sandy Creek Nature Center, Inc., their successors or assigns, from any and all liability due to injury that may result from participation by this teen in the Naturalist Assistant Program.

Also, the health history is correct as far as I know, and the person herein described has permission to engage in all prescribed Naturalist Assistant Program activities, except as noted.

Emergency Authorization: In the event of an emergency, I hereby give permission to the physician selected by the Administrative Staff of Sandy Creek Nature Center to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for the applicant named above.

This form may be photocopied for NAP use.

Signature of Parent or Guardian: _____________________________________ Date:___________ Witness: ________________________________________________________ Date:___________ I also understand and agree to abide with the restrictions placed on my NAP activities.

Signature of Minor:_______________________________________________ Date:____________

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HEALTH HISTORY Name of family physician: _____________________________ Phone: ___________ Date of last physical examination:__________________________ Name of Dentist: _____________________________ Phone: ___________ List current medications: ________________________________________________ Has your teen had the following? If yes, please give approximate dates: Illnesses Frequent ear infections ________ Heart defect/disease ________ Convulsions ________ Diabetes ________ Bleeding/clotting disorders ______ Hypertension ________

Diseases Chicken Pox _________ Measles _________ German measles _______ Mumps _________

Allergies Hay fever ____________ Ivy poisoning, etc. _______ Insect stings ____________ Penicillin ____________ Other drugs ____________ Asthma ____________

Dates of operations or serious injuries: ________________________________________ Disability or chronic recurring illness: ________________________________________ Any specific activities to be limited by physician’s advice: ________________________ ________________________________________________________________________ Has your teen ever received special counseling, attended special classes in school, been the recipient of professional medial supervision or received similar type support and assistance which the SCNC staff need to be aware of in order to meet your teen’s individual needs and insure the best possible experience here at the Nature Center? (note: all health records are confidential) ______________________________________ ________________________________________________________________________ Are there any health considerations of which the SCNC Staff should be aware? ________ ________________________________________________________________________ For Female: Has this person menstruated? _______________ If not, has she been told about it? _____ If so, is her menstrual history normal? ________ Special considerations: _____________

IMMUNIZATION HISTORY Please list month and year when the following immunization series were completed.

DPT(Diphtheria, Pertussis(Whooping Cough), Tetanus) or DT(Diphtheria, Tetanus) ___ MMR (Mumps, Measles, Rubella) ___________ Oral Polio (Sabin) or Injectable Polio (Salk) _______________ Tuberculin test given __________________ (most recent) Other ___________________ If immunizations not up to date, please list current status: _________________________

INSURANCE Do you carry family medical/hospital insurance? Yes or No Carrier: _________________________________________________________________