Tech-Xploration HEALTH & WAIVER FORM

HEALTH HISTORY & MEDICAL AUTHORIZATION FOR ALL PERSONS UNDER AGE 18

This form must be completed and returned with EACH registration. Registrations will NOT be processed unless they are accompanied by this form. NOTE: A doctor's signature is NOT required.

Name of the student:

First:
Last:

Social Security #:

Parent 1 Name:

Daytime Phone:

Email Address:

Parent 2 Name:

Daytime Phone:

Email Address:

Alternate Emergency Contact:

Daytime Phone:

Family Physician:

Daytime Phone:

Please complete the following:

1. Currently under physician's care for:

2. Current medication being taken:

All Medications, including inhalers & epi pens, must be stored at the health services office & administered by the college nurse.

3. Were you ever advised not to allow this child to play in any sports? YES NO

4. List any malfunction or loss of a paired organ:

5. List any allergies including bee stings, hives, asthma:

Select one if applicable:
Child uses epi pen / Child uses an inhaler / Neither
Indicate type:

Child can use this independently: Yes No

Has this child:
(a) had difficulty with sight? Yes* No
(b) had difficulty with hearing? Yes* No

Does this child have a history of fainting with exercise?
Yes* No

Has child experienced recent loss of family member or close friend?
Yes* No

* - Please explain. Specify all known mental and physical conditions (attach extra pages if necessary):

According to state law, all campers must be immunized or submit a statement from a physician, prior to the first day of camp, that immunization is in progress. Please indicate ALL immunization dates for each of the following:

DPT (Diphtheria, Pertussis, Tetanus)
(Measles, Mumps, Rubella)
Last TB /Tetanus Booster
Polio (OPV)

If an emergency illness or injury occurs, I (parent/guardian) hereby authorize NJCATE to treat and/or send this person to a physician or hospital and authorize the necessary treatment. I also authorize the physician or hospital to release my child after treatment to a representative of NJCATE. All information on this form is complete, true and accurate to the best of my knowledge. In addition, I give permission for the above mentioned child to be photographed/video taped during this camp season by a representative of NJCATE. I understand that the photographs/videotapes will be used by NJCATE for the purpose of publicizing and promoting the College's programs and services, and that no compensation will be offered to the child or the family.

I agree I do not agree

For more information or if you have any questions, please contact:
Josephine Lamela
Middlesex County College
2600 Woodbridge Avenue
Edison, NJ 08818
jlamela@middlesexcc.edu
Ph. 732.548.6000 x3007