The Health History form must be completed by a parent or legal guardian if student is 17 or younger.

Please fill out this form in its entirety. If you have any questions, please contact us.

Student Name: *

First

Last

Parent Name:

First

Last

Address:

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Antigua and Barbuda Aruba,Bahamas Barbados Belize Canada Cook Islands Costa Rica Cuba Dominica Dominican Republic El Salvador Grenada Guatemala Haiti Honduras Jamaica Mexico Netherlands Antilles Nicaragua Panama Puerto Rico Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Trinidad and Tobago United States Argentina Bolivia Brazil Chile Colombia Ecuador Guyana Paraguay Peru Suriname Uruguay Venezuela Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Faroe Islands Finland France Georgia Germany Greece Hungary Iceland Ireland Italy Latvia Liechtenstein Lithuania Luxembourg Macedonia Malta Moldova Monaco Montenegro Netherlands Norway Poland Portugal Romania San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Ukraine United Kingdom Vatican City Afghanistan Bahrain Bangladesh Bhutan Brunei Darussalam Myanmar Cambodia China East Timor Hong Kong India Indonesia Iran Iraq Israel Japan Jordan Kazakhstan North Korea South Korea Kuwait Kyrgyzstan Laos Lebanon Malaysia Maldives Mongolia Nepal Oman Pakistan Palestine Philippines Qatar Russia Saudi Arabia Singapore Sri Lanka Syria Taiwan Tajikistan Thailand Turkey Turkmenistan United Arab Emirates Uzbekistan Vietnam Yemen Australia Fiji Kiribati Marshall Islands Micronesia Nauru New Zealand Palau Papua New Guinea Samoa Solomon Islands Tonga Tuvalu Vanuatu Algeria Angola Benin Botswana Burkina Faso Burundi Cameroon Cape Verde Central African Republic Chad Comoros Democratic Republic of the Congo Republic of the Congo Djibouti Egypt Equatorial Guinea Eritrea Ethiopia Gabon Gambia Ghana Gibraltar Guinea Guinea-Bissau Cote d'Ivoire Kenya Lesotho Liberia Libya Madagascar Malawi Mali Mauritania Mauritius Morocco Mozambique Namibia Niger Nigeria Rwanda Sao Tome and Principe Senegal Seychelles Sierra Leone Somalia South Africa Sudan Swaziland United Republic of Tanzania Togo Tunisia Uganda Zambia Zimbabwe Country

Home Phone:

### - ### - ####

Father Work Phone:

### - ### - ####

Father Cell Phone:

### - ### - ####

Mother Work Phone:

### - ### - ####

Mother Cell Phone:

### - ### - ####

Date of Birth:

MM / DD / YYYY

Sex:

Male

Female

In the event of a serious illness or injury, we will attempt to notify you immediately. In case we are unable to locate you, please give us the name of another responsible adult (relative, friend, neighbor, etc.) whom we should try to reach.

Name:

First

Last

Relationship to You:

Address:

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Antigua and Barbuda Aruba,Bahamas Barbados Belize Canada Cook Islands Costa Rica Cuba Dominica Dominican Republic El Salvador Grenada Guatemala Haiti Honduras Jamaica Mexico Netherlands Antilles Nicaragua Panama Puerto Rico Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Trinidad and Tobago United States Argentina Bolivia Brazil Chile Colombia Ecuador Guyana Paraguay Peru Suriname Uruguay Venezuela Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Faroe Islands Finland France Georgia Germany Greece Hungary Iceland Ireland Italy Latvia Liechtenstein Lithuania Luxembourg Macedonia Malta Moldova Monaco Montenegro Netherlands Norway Poland Portugal Romania San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Ukraine United Kingdom Vatican City Afghanistan Bahrain Bangladesh Bhutan Brunei Darussalam Myanmar Cambodia China East Timor Hong Kong India Indonesia Iran Iraq Israel Japan Jordan Kazakhstan North Korea South Korea Kuwait Kyrgyzstan Laos Lebanon Malaysia Maldives Mongolia Nepal Oman Pakistan Palestine Philippines Qatar Russia Saudi Arabia Singapore Sri Lanka Syria Taiwan Tajikistan Thailand Turkey Turkmenistan United Arab Emirates Uzbekistan Vietnam Yemen Australia Fiji Kiribati Marshall Islands Micronesia Nauru New Zealand Palau Papua New Guinea Samoa Solomon Islands Tonga Tuvalu Vanuatu Algeria Angola Benin Botswana Burkina Faso Burundi Cameroon Cape Verde Central African Republic Chad Comoros Democratic Republic of the Congo Republic of the Congo Djibouti Egypt Equatorial Guinea Eritrea Ethiopia Gabon Gambia Ghana Gibraltar Guinea Guinea-Bissau Cote d'Ivoire Kenya Lesotho Liberia Libya Madagascar Malawi Mali Mauritania Mauritius Morocco Mozambique Namibia Niger Nigeria Rwanda Sao Tome and Principe Senegal Seychelles Sierra Leone Somalia South Africa Sudan Swaziland United Republic of Tanzania Togo Tunisia Uganda Zambia Zimbabwe Country

Home Phone:

### - ### - ####

Work Phone:

### - ### - ####

Cell Phone:

### - ### - ####

HISTORY: Has your child had, or is she/he subject to any of the following? Give dates

Appendicitis

Chickenpox

Typhoid Fever

Measles

Mental Illness

Shortness of Breath

High Blood Pressure (or Family History)

Tonsillitis

Mumps

Sinus Infection

Pelvic Disorders

Diabetes

Hay Fever

Pneumonia

Epilepsy

Heart Trouble

Moody

Cough

Joint Pains

Defective Hearing

Jaundice

Kidney Trouble

Hernia

Scarlet Fever

Skin Disease

Rheumatic Fever

Tuberculosis

Headaches

Whooping Cough

Crying

Diphtheria

Asthma

Poliomyelitis

Pleurisy

Malaria

Abdominal Pain

Emotional Problems

Defective Vision

Mononucleosis

German Measles

Other:

Dates of Checked Items:

Injuries:

Please include dates.

Operations:

IMMUNIZATION SCHEDULE (REQUIRED):

Poliomyelitis Immunization - Basic Series - Date:

MM / DD / YYYY

Tetanus Toxoid Booster - Required within the past 10 years - Date:

MM / DD / YYYY

2 MMR (Measles, Mumps, Rubella) - Date:

MM / DD / YYYY

Is the student currently on any medications?

Yes

No

If you chose yes to the previous question, please explain:

Do you authorize McKendree staff members to dispense this medication, as provided by you?

Yes

No

(Please check Yes if child should receive medication while at McKendree)

If your child needs medical attention for an illness or injury, do you authorize the college's staff person to use the local physician?

Yes

No

Name of Health Insurance Company:

Insurance Policy Number:

Information in this medical report may be used to plan health care, adjudicate claims, provide classification for physical activities, and control communicable diseases. In order to provide health care, the contact person(s) you have named above and appropriate health professionals may be given necessary information from this sheet. Its contents will be otherwise confidential.

Please add any further information that might have bearing on your child’s activities at McKendree:

Travel Consent: As parent/guardian, I give my permission for his/her travel with the McKendree University Marching Bearcat Band during the duration of the 2011-2012 academic year.

Yes

No

I certify that the information I have given on this form is complete and correct to the best of my knowledge. I understand that it is my responsibility to update camp staff with any information that could be useful. By initialing and dating below, you agree to electronically sign this document.

Student Initials:

Date:

MM / DD / YYYY

Student ID Number:

Found of McKendree ID card.

Parent Initials:

Date:

MM / DD / YYYY