Health History and Special Needs – Recreation Program

"*" indicates required fields

IMPORTANT INSTRUCTIONS:

Application for participant will not be considered complete without medical insurance information.

Fill out this form only once per participant. If the participant is attending multiple overnight trips, please select ALL the applicable events below.

Any guests of participant will also be required to fill out this form.

If you have any questions regarding this form, please contact Amber Gallegos, Recreation Program Assistant at agallegos@wayfinderfamily.org.

PARTICIPANT INFORMATION

Participant's Name *

First Last

Date of Birth *

Age *

Gender Identity *

Participant's Email *

All communication regarding your health history questionnaire will be sent to this email address.

Enter Email Confirm Email

Emergency Contact Name *

Please provide the name of a person to contact in case of an emergency. Do not list yourself as the emergency contact.

First Last

Relationship to Participant *

Emergency Contact Email *

Enter Email Confirm Email

Emergency Contact Primary Phone *

Emergency Contact Secondary Phone

PHYSICAL MOBILITY NEEDS

PHYSICAL: Does the participant use any of the following? *

Please select all that apply.

Walker

Crutches

Wheelchair

Has trouble walking/standing for long periods of time

None of the above

Please provide more details: *

PERSONAL CARE NEEDS

INDEPENDENCE: Does the participant need assistance with any of the following? *

Please select all that apply.

Requires assistance with feeding

Requires assistance with using the bathroom

Requires assistance with showering

Requires assistance with dressing

Requires assistance ambulating (walking)

Requires assistance communicating

Has a history of bedwetting

Requires assistance with tasks other than those listed

None of the above

Please provide details: *

DIETARY NEEDS AND ALLERGIES

DIETARY NEEDS: *

Please select all that apply.

Vegetarian

Vegan

Dairy / Lactose Free

Gluten Free

Other Food Allergies

None of the above

Please provide details: *

Allergies

Please select allergies below: *

Please select all that apply.

Insect Stings: Please provide more information *

Allergies to medications not listed: *

Allergies to food not listed: *

Any other allergies not listed: *

DISABILITIES OR MEDICAL CONDITIONS

Participant's Vision *

Does the participant have any of the following: *

Please select all that apply.

Intellectual Disability: Please provide more details *

Emotional Disorder: Please provide more details *

Depression: Please provide more details *

Anxiety: Please provide more details *

Eating Disorder: Please provide more details *

Behavioral Disorder: Please provide more details *

Other disabilities not listed: *

Other medical conditions not listed: *

Other psychiatric or mental health condition not listed: *

Seizures or Epilepsy

Date of Last Seizure *

Typical seizure duration: *

Frequency: *

Potential triggers: *

Asthma

Date of last attack: *

Inhaler *

Uses an inhaler

Does not use/need inhaler

Potential triggers: *

Medication

Does the participant have an EpiPen? *

Yes

If you carry an EpiPen, please list the specific allergy (e.g., peanuts, insect stings) that requires its use. *

Does the participant take medication? Please include any OTC medications. *

Yes

Medication Administration *

Please list all medications and dosage details below. Please list one medication per line. Use the + sign on the right to add more fields for each medication.

Name of Medication

Dosage

Route

Time/Frequency

Comments

Do any of the medication need refrigeration? *

Yes

Tuberculosis Screening

Participants in the Recreation Program at Wayfinder Family Services no longer need to submit a negative TB skin test to attend organized overnight activities. Please answer the screening questions truthfully, and Wayfinder staff will contact you if further steps are required before attending an organized overnight activity. Thank you.

Have the participant ever had a positive skin or blood test for TB? *

Yes

Have the participant ever been told they have an abnormal chest x-ray? *

Yes

In the last 2 years, have the participant lived with or spent time with someone who has been sick with TB? *

Yes

Have the participant lived or traveled to Africa, Asia, Pacific Islands, Central America, South America, Mexico, Eastern Europe, The Caribbean, or the Middle East for more than one month? *

Yes

Insurance Information

Please upload a photo of your participant's insurance/Medi-Cal card. If you are unable to upload, please send via email.

Insurance/Medi-Cal information

Max. file size: 50 MB.

Electronic Signature: *

TERMS & CONDITIONS

Authorization for Third Party to Consent to Treatment of Minor Lacking Capacity to Consent

This health history is correct and accurately reflects the health status of the participant to whom it pertains. The person described has permission to participate in all activities except as noted by me and/ or an examining physician.

I, the undersigned, parent/legal guardian of the aforementioned participant, do hereby authorize Wayfinder Family Services, Camp Bloomfield and its employees as agent (s) for the undersigned to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care, which is deemed advisable by, and is to be rendered under the general or special supervision of, any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of any hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

The undersigned understands and agrees that Wayfinder Family Services, Camp Bloomfield and its employees shall not be legally or financially liable for any claim arising from any medical care or dental care provided pursuant to this authorization. The undersigned hereby agrees to indemnify and to hold Wayfinder Family Services, Camp Bloomfield and its employees harmless from any claim made by or on behalf of said minor arising out of any medical care or dental care provided pursuant to this authorization.

This includes authorization to consent to any X-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care, which is deemed advisable by and is to be rendered to the minor by or under the supervision of a dentist licensed under the provisions of the Dental Practice Act. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority to power on the part of our aforesaid agent (s) to give specific consent to any and all such diagnosis, treatment or hospital care which a physician, meeting the requirements of this authorization, may, in the exercise of his/her best judgment, deem advisable. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California.

I hereby authorize any hospital which has provided treatment to the aforementioned participant pursuant to the provisions of Section 25.8 of the Civil Code of California to surrender physical custody of such minor to my above-named agent (s) upon the completion of treatment. The authorization is given pursuant to Section 1283 of the Health and Safety Code of California. This authorization will remain effective while the aforementioned participant is involved or participating in any Wayfinder Family Services, Camp Bloomfield program or activities, unless revoked in writing by the undersigned and delivered to the aforesaid agent (s).

CALIFORNIA CIVIL CODE SECTION 25.8

S25.8 Minor- Consent to Furnishing of Hospital or Medical Care by Adult other than Parent - Lg. H. 1965 ch.1524

Either parent if both parents having legal custody, or the parent or person having legal custody or the legal guardian, of a minor may authorize in writing any adult person into whose care the minor has been entrusted to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care to be rendered to said minor under the general or special supervision and upon the advice of a physician and surgeon licensed under the provisions of the Medicine Practice Act or to consent to any X-ray examination, anesthetic, dental or surgical diagnosis or treatment and provisions of the Dental Practice Act.

Type your full name to sign.

Program Areas

IMPORTANT INSTRUCTIONS:

PARTICIPANT INFORMATION

PHYSICAL MOBILITY NEEDS

PERSONAL CARE NEEDS

DIETARY NEEDS AND ALLERGIES

Allergies

DISABILITIES OR MEDICAL CONDITIONS

Seizures or Epilepsy

Asthma

Medication

Tuberculosis Screening

Insurance Information