Eastern Kentucky University-UB-Health Form

STUDENT HEALTH HISTORY AND PARENT CONSENT FORM

UPWARD BOUND EASTERN KENTUCKY UNIVERSITY
Student's Full Name:*

First NameLast Name
Email*
example@example.com
Birthdate

MonthDayYear
mm-dd-yyyy
Social Security Number
999-99-9999
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name

First NameLast Name
Relationship
Parent/Guardian Phone Numbers:
Cell Phone:
(999)999-9999
Home Phone:
(999)999-9999
Work Phone:
(999)999-9999
Health Insurance Carrier
Policy #
Student’s Physician
Physician’s Phone
Does the student know how to swim?

YesNo
Does the student have any physical or health limitations and/or disabilities (whether temporary or permanent) that would limit safe participation in the Upward Bound activities?

YesNo
If yes, please indicate:
Does the student have any chronic or recurring injuries?

YesNo
Has the student had a kidney transplant?

YesNo
Is the student pregnant?

YesNo
Health Checklist: Please check the following physical disabilities or conditions that may limit the student’s participation:

Hearing or vision problemsRespiratory problemsBack problemsJoint problemsRecent serious illnessRecent surgeryRecent hospitalizationSerious reaction to high or low temperatures Frequent muscle crampsHigh or low blood sugarSeizuresHeart problemsAsthmaOther

Allergies: Indicate any allergies, your reaction, and treatment:

	Allergy	Reaction	Treatment
1
2
3

Additional Emergency Contact Information

In the event of an emergency, and the parent/guardian cannot be reached, please indicate another emergency contact.
Name:

First NameLast Name
Relationship to Student:
Phone:
(999)999-9999
Medications: Please indicate all medications student is currently taking, the condition for which medication is needed, and if that medication will be needed during Upward Bound activities. If so, make sure student has medication with them.

Medications

	Medication	Dosage	Condition	Needed during program activities?
1
2
3
4
5

The student may keep their personal medications during Upward Bound activities. However, Upward Bound staff will not give any medication to the student without your verbal or written permission. The student is also not permitted to give medication to another student.
Please indicate which of the following you give permission to Upward Bound Staff to administer to the student as needed:

AdvilTylenolAspirinImodiumPepto BismolTumsBenadrylOther: Explain
Dietary allergies or restrictions:
I hereby give permission for {main_name} to participate in the Upward Bound activities during the 2024-2025 academic year beginning June 1, 2024 thru May 31, 2025.

In case of an injury, I grant permission for {main_name} to receive medical attention deemed necessary by qualified medical personnel during the entire time that he or she (listed within) is participating in the Eastern Kentucky University Upward Bound Program.

PARENT/GUARDIAN: Every reasonable precaution will be taken to provide safety and care for the student. Every effort will be made to notify you in the event of an accident or injury which may require emergency care. If you cannot be contacted, permission is granted to the staff to seek medical attention. All financial responsibility for hospitalization and medical care provided in the case of an emergency is to be assumed by the parent/guardian.
Signature of Student*

Clear
Date

MonthDayYear
mm-dd-yyyy
Signature of Parent/Guardian (if student is under the age of 18)*

Clear
Date

MonthDayYear
mm-dd-yyyy

STUDENT HEALTH HISTORY AND PARENT CONSENT FORM

Additional Emergency Contact Information