Old Westbury Seventh-day Adventist Church

Giving

TRAILBLAZER PATHFINDER CLUB HEALTH FORM

Pathfinder Club Health Form

This field is for validation purposes and should be left unchanged.
Name*
Address*
MM slash DD slash YYYY

Medical History and Information

The following information is critical for the safe care of your Pathfinder during routine Pathfinder activities and emer-gencies. Please answer all questions as to “yes” or “no” & if “yes” explain with additional information.
Does your child have any health history? (Asthma, Constipation, Epilepsy, Diabetes, etc)
Does your child have any difficulties that would effect them during Pathfinder activities?
Does your child have any allergies to medications? Please list with reaction.
Does your child have any allergies to foods, insects, or seasonal? Please list with reaction.
Are there any dietary considerations which should be considered when planning a menu?
Are there any physical restrictions that would effect your child during Pathfinder activities?
All Pathfinders are required to have up to date shot records, are there any shots that are not?
Is your child currently on any medications? If “yes” please list with dosage.

Insurance/Physician/Emergency Contact Information/Parent or Guardian

Primary Physician's Name*
Emergency Contact Name*
Father's Name*
Mother's Name*

Parent/Legal Guardian Atestation

Being the Parents/Guardians of the applicant I/we certify the above medical history and information is correct to the best of our knowledge and the applicant has permission to engage in all Pathfinder activities except those noted. In the event the I/we cannot be reached in an emergency, permission is given to the adult leader to whom the applicant is charged to hospitalize, secure proper anesthesia or physician, order injection, surgery, resuscitation, or any care deemed necessary by that leader or physician to insure safe return of said applicant to his/her Parents/Guardians. In addition, I have read and understand the Emergency Authorization statement and give my full consent to the terms found therein. Permission for photo copying of this health record is granted.
Parent/Legal Guardian's Name*
MM slash DD slash YYYY