INSTRUCTIONS FOR COMPLETION AND SUBMISSION OF CPYB 5-WEEK SUMMER BALLET PROGRAM S HEALTH FORM PACKAGE All families are required to complete and submit ALL pages of this Health Form Package for their student to CPYB by May 1, 2015. This information is required to ensure CPYB s ability to provide the best care for your student while living away from home for the 5WSBP. Directions: Step 1 Print the health form package in its entirety. Step 2 Complete the information on page 2 by providing the student name, insurance coverage information, and credit card information for emergency fees that the student would accumulate at local medical facilities during their stay in Carlisle, PA. Step 3 Please make a copy of the insured s insurance cards front and back; and add the copies as pages 8-9 of the health form packet. Step 4 Complete the information on pages 3 and 4 to provide a health care facility the medical history of your student for use in an emergency visit. Please sign, state relationship to the student, and date page 4. Step 5 NOTE: Page 5 must be completed and signed by a PHYSICIAN. A copy of a PREVIOUS PHYSICAL EXAMINATION can be used if dated AUGUST 1, 2014 OR LATER. If the student has a chronic health condition, a PLAN OF ACTION (Page 6) MUST BE PROVIDED BY THE PHYSICIAN in order to complete CPYB records to act in an emergency. Step 6 Page 7 requires a parental signature for CPYB to provide necessary evaluation, treatment or emergency care on Dickinson and CPYB properties as well as activity trips during the period of enrollment at CPYB 5-Week Summer Ballet Program. Step 7 Submit the entire health form package by either of these methods: 1) email a scanned copy to info@cpyb.org or 2) mail to Central Pennsylvania Youth Ballet, ATTN: Logistics, 5 North Orange St, Suite 3, Carlisle, PA 17013-2727. No health forms will be accepted on arrival day. All families should plan to have the package arrive by May 1, 2015, including the signed physician form and if required, the Chronic Health Condition Plan of Action. You may not arrive on campus without the health form package. CPYB s care of your student begins the moment they arrive at Dickinson College for registration check-in. 1
(Must be fully completed and updated yearly) Name: Birthdate - - Gender: M F First Middle Last Race (circle all that apply) Indian Asian Black White Hawaiian Hispanic Unknown Primary Language Spoken DOES THE PATIENT HAVE INSURANCE COVERAGE? YES NO Primary Insurance Policy Holder s Full Name: Relationship to student: other ather Address: Birthdate: Phone: Name of Insurance Plan: Secondary Insurance Policy Holder s Full Name: Relationship to student: other ather Address: Birthdate: Phone: Name of Insurance Plan: If more than one insurance - have you completed your coordination of benefits form for this year? Yes No Please use the following card for any Emergency Fees that the student accumulates. CPYB must have your credit card information on file in the event your insurance denies your claim at local medical facilities. The financial information in the family portal is stored offsite in an electronic vault for the School Management System but is not accessible or viewable by CPYB, the Carlisle Pediatrics Center, the Carlisle Regional Medical Center, or the Holy Spirit Health System. Credit card must be valid until at least 09/2015 Visa MasterCard Discover AMERICAN EXPRESS IS NOT ACCEPTED Card Number: Expiration Date: Name as it appears on the card: Security Code: (Three digit code on back of card) Card Billing Address: Signature: Date: CPYB requires a copy of your insurance cards, both front and back, including dental/prescription cards. Please provide copies on a separate sheet and label as page 8 CPYB does not keep your credit card information on file after the summer program has ended. Your information is shredded and disposed of. 2
This form must be completed and returned. The following is VERY IMPORTANT to your child s health. Please complete it ACCURATELY AND COMPLETELY. Child s full name: Birthdate - - Where was your child born? Is your child adopted or fostered? Yes No ALLERGIES NO YES If yes, explain This child has No Known Drug Allergies If you answered NO, is your child allergic to: Penicillin Cephalosporin Sulpha Macrolides Other antibiotics Name: Peanuts Milk Eggs Seafood Other foods Name: Bees/wasps Indoor allergens Outdoor allergens Animals Breed: Latex PATIENT PAST MEDICAL HISTORY NO YES If yes, explain Serious accidents or injuries Surgeries Hospitalizations What age: Chicken pox disease Frequent ear infections or sinus infections Frequent sore throats or tonsillitis Other infection illnesses Allergic rhinitis or other allergy Asthma, bronchitis, bronchiolitis, pneumonia or croup Heart problems or murmur Abdominal pain/ger Constipation requiring doctor visits Bladder or kidney infection or other urologic problem Bed-wetting (after age 5) Eye conditions /wear corrective lenses Problems with ears or hearing Chronic or recurrent skin problems acne Anemia or bleeding problem Past blood transfusion Frequent headaches Seizures, developmental delays, ADD/ADHD or other neurologic disorders Mental health concerns Orthopedic problems Diabetes Thyroid or other endocrine problems If female, have menstrual periods started? If female, any problems with periods? Use of alcohol or drugs? Emotional problems Other significant issues: 3
FAMILY MEDICAL HISTORY NO YES If yes, explain Nasal allergies or other allergies Asthma/lung disease Heart disease or heart condition High blood pressure High cholesterol Diabetes or other endocrine problem Cancer Anemia Bleeding disorders Epilepsy or convulsions Mental retardation or developmental disorders Neurologic disorder including ADHD/ADD Liver disease Other GI disease / disorder Kidney disease Bed-wetting (after age 10) Hearing impairment Vision impairment or eye disorder Immune problems, recurrent infections or HIV/AIDS Alcohol abuse Drug abuse Mental illness Tuberculosis Other issues: SOCIAL HISTORY NO YES If yes, explain Lives with both mother and father in same house Non-intact home give custody status Lives with: Visitation status of non-custodial parent Are there siblings? Are there pets in the home? Are there guns in the home? Are guns locked and kept separate from ammunition? Other issues: Patient s Printed Name: Is there anything else regarding your child s health that you think we should know that has not already been asked? I attest that all the medical history information is true and correct to the best of my knowledge: _ Signature Relationship to patient Date 4
The following information must be supplied by a Licensed Health Care Practitioner. Any changes to this form should be provided to Central Pennsylvania Youth Ballet personnel upon participant s arrival at CPYB. This information is considered invalid without the signature of a Health Care Practitioner at the bottom of this page. This form must be completed in full and signed by a Licensed Health Care Practitioner within 10 months of the start of the 5-Week Summer Ballet Program. Without submission of this form, the student WILL NOT be able to participate in the 5-Week Summer Ballet Program. : BP: Pulse: Height: Weight: General Health Information: Check all applicable boxes. Explain any positive responses below. Recent illness, injury Chest pain during/after exercise Hospitalization High blood pressure Glasses/contacts Problems with joints Orthodontic appliance Dizzy during/after exercise Explain any checked boxes: Immunizations Record: MMR#1: #2: Most recent tetanus immunization date: Hepatitis B #1: #2: #3: Varicella (or chickenpox disease): Has the student had to limit dance activities during the last 6 months due to injury? Yes No Explain: Has the student been evaluated/treated for an eating disorder, depression, anxiety or panic disorder? Yes No Explain: Use this space to provide any additional information about the student s behavior and physical, emotional, or mental health about which CPYB should be aware: Health Care Recommendations: This person is under the care of a health care provider for the following condition(s): Treatment includes (IF APPLICABLE, PLEASE USE THE PLAN OF ACTION FOR CHRONIC HEALTH NEEDS FOR USE IN THE STUDIOS AND THE DORMITORIES) Limitations on activity or dietary recommendations: I have examined the aforementioned person and find him/her to be physically, mentally and emotionally capable of participation in a rigorous and intensive summer ballet program. Signature of Licensed Health Care Provider: Date: Printed name: License #: Address: Phone: Fax: Email: 5
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I hereby give permission to the medical personnel selected by the Central Pennsylvania Youth Ballet director (including but not limited to physical therapists, trainers, staff of the Health Center of Dickinson College, CPYB health staff, urgent car facilities, emergency room staff and any consultants that they may deem necessary) to provide assessment, treatment, appropriate diagnostic testing or hospitalization for my child; to release any records necessary for insurance purposes and to provide necessary transportation for health care services. I agree to assume all financial responsibility for medical costs incurred by the student. It is the responsibility of students and their parents to determine whether their insurance will cover any and all services that are recommended or provided during their participation in the CPYB 5-Week Summer Ballet Program. I give permission for CPYB to contact my child s medical provider for the purpose of confirming medical conditions/treatments or obtaining additional information in order to provide appropriate care. I agree to the best of my knowledge this health history is correct and complete. A photocopy of this form shall serve in the same capacity as the original document. Date Signature of Parent, Guardian or Student (if over 18 years of age) 7