Wood County Society

    Medical Consent Form

    Participant Information

    Date of Birth:
    Age:
    Height:
    Weight:
    Sex: FemaleMale
    Mailing Address:
    City
    State:
    Zip Code:
    Primary Disability:
    Other medical diagnoses, if any:
    Has participant received a COVID-19 vaccination? NoYes
    If YES, please provide a copy of the vaccination card via the Attachments section below. If NO, please explain the reason (i.e. health condition or not advised by medical professionals)
    Does the participant have health concerns that would inhibit wearing a mask? NoYes
    Is the patient allergic to latex NoYes
    Is the participant allergic to cleaners such as Lysol, Bleach, and Disinfectant Sprays? NoYes

    Parent/Caregiver Contact Information

    Parent/Caregiver:
    Mailing Address:
    City:
    State:
    Zip Code:
    Best Contact Number:
    Email:

    Emergency Contacts

    Please list (in order) the perosn we should call in the event of a medical, behavioral, or other emergency.

    Name:
    Relationship to participant:
    Phone (Primary):
    Phone (Mobile):
    Name:
    Relationship to participant:
    Phone (Primary):
    Phone (Mobile):
    Physician Name:
    Physician Phone:

    Insurance

    A front and back copy of all insurance cards must be attached below.

    Primary Health Insurance:
    Policy Number:
    Policy Subscriber Name (if different than participant):
    Secondary Health Insurance:
    Policy Number:
    Policy Subscriber Name (if different than participant):

    Medical Information

    All medications will be turned over to the medical staff at the time that participants are checked in. All medications (including non-prescription) will be dispensed by the designated member of that staff. All medications are to be in original pharmacy-labeled medication containers. If the participant currentlyt has a MAR sheet, it must be attached to this form below. If a participant does not require the use of a MAR, all medications must be listed below.

    MAR Sheet attached: NoYes
    Medication:
    Dosage/Frequency:
    Medication:
    Dosage/Frequency:
    Medication:
    Dosage/Frequency:
    Medication:
    Dosage/Frequency:
    Medication:
    Dosage/Frequency:
    Best person to call regarding medication questions:
    Does this participant have food, drug, or bee allergies? No food, drug, or bee allergiesFoodDrugBee
    Please list any food allergies:
    Please list any drug allergies or interactions:
    Does this participant require support procedures that must be administered by a qualified staff person? NoYes
    Please describe any required support needs (i.e. feeding tube, catheter):
    Does this participant have seizures? NoYes
    Date of last seizure:
    If the participant has seizures, please note the type, frequency, and length:

    The following non-prescription OTC medications may be available for use on an "as needed" basis to manage illness and injury. Please mark all that camp staff are allowed to administer to the participant, even if already listed on MAR.

    Aspirin: NoYes
    Ibuprofen (Advil, Motrin): NoYes
    Benadryl: NoYes
    Acetaminophen (Tylenol): NoYes
    Pepto-Bismol: NoYes
    Epi-Pen: NoYes
    Does the participant have any dietary restrictions? NoYes
    If yes, please explain.
    Does the participant have special food/liquid needs as described (i.e. puree, feeding tube, etc)? NoYes
    If yes, please explain.

    Attachments

    Insurance Card (Front):
    Insurance Card (Back):
    COVID-19 Vaccination Card:
    MAR Sheet:
    Self/Parent/Guardian Signature:
    Date: