NAME OF APPLICANT: INTERNATIONAL SUMMER PROGRAMS ...

NAME OF APPLICANT: _______________________________OFFICE USE ONLYGROUP/ BUS _____________Date Received:Reviewed by:Follow up:INTERNATIONAL SUMMER PROGRAMSMEDICAL EXAMINATION FORM212-533-7800 x1145Check Program: USY on Wheels_ Classic _ MM_ East _PNW USY Israel Pilgrimage_E. Europe _ Poland_L’takayn _Adventure_ Adv. Plus! _Italy Summer in the City NATIVUNITED SYNAGOGUE YOUTHof the United Synagogue of Conservative JudaismNotes to the Examining Physician:I) The new and strenuous environment each participant will face taxes physical and mental capabilities to the fullest. It is, thereforeimperative, as a safeguard to the health of the participant, that this report be as complete and precise as possible.II)Participants in Israel will be touring and working in a sub-tropical climate, with temperatures reaching 100 degrees Fahrenheit in theshade. The climate is mostly dry, with semi-arid conditions over a large part of the country.III) Participants will be living in a communal environment. He/she will be sleeping in a dormitory or sharing living quarters with many otherpeople, eating in communal dining facilities and sharing bathroom facilities.IV) The participant’s activities may include physical labor in the sun. He/she will also be expected to participate in a number of tours,which will include walking long distances, climbing and other strenuous activities.V) The physician should also bear in mind that medical facilities available for participants only cover acute illness, and minor illness.THERE ARE NO FACILITIES AVAILABLE WITHIN THE FRAMEWORK FOR TREATMENT OF CHRONIC DISTURBANCES.Dental treatment, eyeglasses, contact lenses and psychiatric treatment are not included and will be arranged at the parent’s expense.While in Israel, medical care will very often be entrusted to fully trained paramedical personnel, although a doctor will always beavailable and on call, as well as the local hospital. In some cases, the patient will be transferred to Jerusalem for specializedtreatment when necessary, and where indicated, will later be returned to the country of origin for further treatment. While in NorthAmerica, we will utilize hospital emergency rooms in the case of an emergency or need for medical treatment.VI) a) THIS FORM SHOULD BE FILLED OUT BY A PHYSICIAN WHO HAS KNOWN THE APPLICANT FOR AT LEAST 18 MONTHSPRIOR TO THE FILLING OUT OF THE FORM. IN ADDITION, ANY APPLICANT WHO HAS BEEN UNDER THE CARE OF ASPECIALIST (FOR EXAMPLE, CARDIOLOGIST, NEUROLOGIST, PSYCHIATRIST, PSYCHOLOGIST, SOCIAL WORKER, ETC.)MUST SUBMIT A WRITTEN, DETAILED REPORT FROM SUCH SPECIALIST GIVING COMPLETE DIAGNOSIS, PROGNOSISAND EVALUATION.b) If an applicant is required to continue on therapy or treatment, or to continue receiving medicines and drugs while under theauspices of the program, he/she must have a medical letter giving full details. Since periodically, medicine is not available underthe same trade name, the full pharmacological name of all medicines and drugs used by the patient should be given. Medicationmay only be taken under staff supervision.c) If any change takes place in the applicant’s condition within the last 10 days before departure, the applicant must submit, beforedeparture, a full explanatory medical letter, detailing diagnosis, prognosis and treatment, and a failure to submit such letter mayresult in expulsion of the applicant from his/her program without any refund, at the discretion of the staff.VII) PLEASE PROVIDE US WITH A FULL MEDICAL AND PSYCHIATRIC HISTORY OF PATIENT AS POSSIBLE SO WE MAY FULLYCARE FOR HIM/HER. The Department of Youth Activities, United Synagogue of Conservative Judaism, intends to rely on thiscompleted form and supplementary letters in making determinations of acceptance for or continuation of the applicant in the program.Omissions or misstatements are the risk of the applicant and his/her parents, physician, surgeon, psychiatrist, psychologist or socialworker.VIII) The information on this report form, and all supplementary letters and reports on the physical, mental or psychological condition of theapplicant shall be held by the Department of Youth Activities as strictly confidential.IX) SHOULD ANY PARTICIPANT UPON ARRIVAL, OR DURING HIS/HER STAY ON THE PROGRAM, BE FOUND TO BESUFFERING FROM ANY CONDITION MENTAL OR PHYSICAL THAT IS NOT FULLY DISCLOSED IN THIS MEDICAL FORM, ORIN AN ACCOMPANYING LETTER FROM A QUALIFIED MEDICAL OR PSYCHOLOGICAL PROFESSIONAL, THEN (1) HE/SHEMAY, AT THE SOLE AND ABSOLUTE DISCRETION OF USY OR ITS REPRESENTATIVES, BE RETURNED TO HIS/HER HOMEAT THE PARENT’S OWN EXPENSE, OR MAY BE TREATED UNDER THE AUSPICES OF THE PROGRAM AT THE PARENT’SOWN EXPENSE, AND THERE SHALL BE NO REFUND OF MONIES PAID FOR THE PROGRAM AND (2) USY AND ITSREPRESENTATIVES ARE THEREBY RELEASED OF ALL RESPONSIBILITY OR LIABILITY OF ANY KIND WHATSOEVERARISING OUT OF ANY ASPECT OF SUCH PARTICIPANTS MEDICAL HISTORY AND MENTAL OR PHYSICAL CONDITION.

Name of ApplicantHome Address:PERSONAL HEALTH HISTORYTo be completed by applicant or parent—PLEASE TYPE OR PRINT ALL INFORMATION(First) (Last) (Middle)Social Security # Date of Birth / / Gender: Male FemalePARENT/ GUARDIANName:Phone:Applicant lives with Father Mother BothIN CASE OF EMERGENCY CONTACT:Name:Phone:Business Phone:Parents are Married Divorced Separated WidowedRelationship to Participant:FAMILY HISTORYFather’s Name: Living Deceased Cause of Death and Date:Mother’s Name: Living Deceased Cause of Death and Date:Brothers/Sisters (Number) Living Deceased Cause of Death and Date:HEALTH HISTORY (Answer “Yes” or “No” and give dates for all “Yes” answers) Has/Does the participant have…NO YES NO YESChest pain during or after exercise? ___/___Any skin problems (e.g., itching, rash, acne)? ___/___Chronic or recurring illness/condition? ___/___Asthma? ___/___Dizzy or passed out during or after exercise? ___/___Back problems? ___/___Ever been knocked unconscious? ___/___Bringing an orthodontic appliance with you? ___/___Frequent ear infections? ___/___Diabetes? ___/___Frequent headaches?Head injury?High blood pressure?Hospitalized? ___/___ ___/___ ___/___ ___/___Diagnosed with a heart murmur? ___/___Ever had an eating disorder? Anorexia Bulimia ___________ ___/___Ever had emotional difficulties for which professionalhelp was sought? ___/___Had mononucleosis in the past 12 months? ___/___Motion Sickness? ___/___Had problems with diarrhea/constipation? ___/___Recent injury, illness or infectious disease? ___/___Have a history of bed-wetting? ___/___Seizures? ___/___Have problems with sleepwalking? ___/___Surgery? ___/___If female, have an abnormal menstrual history? ___/___Wear glasses, contacts or protective eye wear? ___/___Problems with joints (e.g., knees, ankles)? ___/___Please explain any “Yes” answers. Feel free to attach sheets.

NAME OF APPLICANT: _______________________________1. Have you or any of your family suffered and/or been hospitalized for: any Chronic or Recurring Illness, Tuberculosis,Mental illness, Epilepsy, Venereal Disease, Heart Disease, Asthma, Diabetes, other Diseases? If yes, give details,including name and addresses of physicians and hospitals, and furnish specialist’s letter (See note VI, p1)2. Have you undergone any operations or sustained any serious injuries?3. Have you ever been diagnosed and/or treated for ADD or ADHD? If so, please give specifics and provide letter fromoverseeing physician in regard to diagnosis and treatment.4. Have you ever consulted a psychiatrist, psychologist or social worker? If so, give dates, reason and consultant’s name,address and telephone number. (A letter and a written detailed report from specialist giving complete diagnosis,prognosis and evaluation must be submitted. See note VI, Page 1).5. Have you ever undergone psychoanalysis or received psychotherapy or other psychological treatment or advice? If so,give dates, reason and therapist’s name, address and phone number. (See note VI, page 1)6. Do you wear/ have you ever worn back brace/ leg brace? If so, please state name and condition.7. Use this space to provide any additional information about the participant’s behavior and physical, emotional, or mentalhealth about which USY Summer Programs should be aware.ALL ABOVE INFORMATION MUST BE FILLED OUT COMPLETELY AND WILL BE TREATED CONFIDENTIALLY.

PHYSICAL EXAMINATION(To be completed by a licensed MD/DO/PA/NP)NAME OF APPLICANT: _______________________________________ Date of Birth: ____/____/____ Sex: F / MHeight _____ft________in Weight ____________lbs BP______/______ Date of Exam:________________NORMAL ABNORMAL DESCRIBE ABNORMALITYGeneral BuildHead, EyesEarsNoseTeeth, Mouth, ThroatNeckChest, LungsHeartAbdomenGenital/UrinaryHerniaExtremitiesSpineSkin, LymphaticsNervous SystemPsychologic/EducationalLAB: Urinalysis ________________ Protein_______________ Sugar ___________VISION: Without Correction Corrected Without Correction CorrectedRight 20/_____ 20/______ Left 20/______ 20/______HEARING:Right: 25 db 35 db Left: 25 db 35 dbMenstrual History:Regular irregular Date of last period: ____________ Other GYN Abnormalities:Full Physical Activity: Y NAllergies: Y NSpecial Diet:Restrictions:□ food: ___________________□ insect: _____________________ □ medicine: _____________□ other: _________________Type of allergic reaction: □ anaphylaxis □ local reactionResponse required: □ none □ epi pen □ other: _______________________________Which of the following hasthe participant had: ADD/ADHD Asthma Cancer Chicken Pox Diabetes German Measles Hepatitis A Hepatitis B Hepatitis C Kidney Disease Measles Mumps Pneumonia Rheumatic Fever Seizures Tuberculosis OTHER: ______________________TB Risk Assessment: Neg POSMantoux Test Requiredif Positive Risk:Date of last test _____Result _______mmUp to date immunizations are required for all USY Summer Program participants, asstated in the policy manual for your program. Please give dates for all immunization for:VaccineMo/Yr Mo/Yr Mo/Yr Mo/Yr Mo/Yr Mo/YrDates:DTPPolio (IPV or OPV)Tetanus Booster(Tdap or Td)MMR (Measles,Mumps, Rubella)Hepatitis AHepatitis BPneumococcal(PCV)Haemophilusinfluenza BVaricella (ChickenPox)MeningococcalMeningitis (Menactra)Guardisil (HPV)

MEDICATIONS BEING TAKEN This person takes NO medications on a routine basis.NAME OF APPLICANT: _______________________________Please list ALL medications (including over-the-counter or nonprescription drugs) taken routinely. (See Note VI, page 1).Bring enough medication to last the entire time on your program. Keep it in the original packaging/bottle that identifies theprescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration. This person takes medications as follows:PhysicianInitialMed #1 ____________________________ Dosage _________ Specific times taken each day ______________________Reason for taking _______________________________________________________________________________Med #2 ____________________________ Dosage _________ Specific times taken each day ______________________Reason for taking _______________________________________________________________________________Med #3 ____________________________ Dosage _________ Specific times taken each day ______________________Reason for taking _______________________________________________________________________________Attach additional pages for more medications.Please identify any medications taken during the school year that participant does/may not take during the summer:______________________________________________________________________________________________NOTE: Due to the nature of USY Summer Programs, we strongly advise you to discuss with your doctor the discontinuationof any medications during the summer.NOTE: Physician must initial each medication dosage/frequencyALLERGIESList all known. Describe reaction and management of the reaction.Medication allergies(list)Food allergies(list)Other allergies— include insect stings,hay fever, asthma, animal dander, etc.Please give all details concerning anydisease or allergy as to which “Yes” isanswered above, including names andaddresses of physicians and hospitals.(list)PHYSICIAN’S STATEMENTI have read the “Notes to the Examining Physician” on page one and therefore have examined ________________________________and have recorded the results above which represent to the best of my knowledge all the applicant’s medical history and my findings onexamination. In my opinion the applicant is capable is incapable of participating in the program as outlined in the Notes. I have knownthe applicant for ____________ years. To the best of my knowledge the information on pages two, three and four is correct. I understandthat the Department of Youth Activities of the United Synagogue of Conservative Judaism will rely on my above report and findings.PLEASE TYPE:Name:Address:Phone:Date:______________________________________________________ __________________________________________Stamp & Signature of Physician(License Number)*If you become aware of a change in the applicant’s medical condition, please notify the Department of Youth Activities immediately.

APPLICANT’S STATEMENTNAME OF APPLICANT: _______________________________I hereby certify that the attached Physician’s Health Statement was completed by the physician only after examination of theapplicant, _______________________________. This is a full and complete statement of the applicant’s health submitted toyou as part of the application for admission to a USY Summer Program.I understand that the medical care provided for participation in the program does not include already pre-existing conditions(i.e. allergies, asthma, ulcers, previous operations, etc.) eyeglasses, pregnancy, or dental treatment of any kind.The attached physician’s statement of health states in detail all medications which applicant is required to take regularly, andsuch medication will be supplied by the applicant at his/her expense.I understand that if, after departure, the applicant becomes ill, or unable to participate in the program, and such illness orinability is related in any way to any pre-existing or undisclosed condition of which USY had no knowledge, in writing,applicant may not be permitted to continue in the program and any medical treatment will be at his/her expense, and USYand its representatives have neither responsibility nor liability arising out of such condition.I hereby give permission to the camp to provide, seek, and consent to routine health care, administration of prescribedmedications, and emergency treatment for my child, as may be necessary, including, but not limited to x-rays, routine testsand treatment, and/or hospitalization. I also give permission for USY Summer Programs to arrange related transportation. Iagree to the release of any records necessary for treatment, referral, billing, or insurance purposes.It is my intention that USY Summer Programs be treated as acting in loco parentis if the person herein named is a minor.Further, it is my intention that the appropriate representatives of USY Summer Programs be treated as “personalrepresentatives” for the purposes of disclosing protected health information pursuant to the privacy regulations promulgatedpursuant to the Health Insurance Portability and Accountability Act of 1996. I hereby agree (pursuant to 45 CFR §164.510(b)) to the disclosure to USY’s representatives of the protected health information of the person herein described, asnecessary: (i) to provide relevant information to USY’s representatives related to the person’s ability to participate in USY’sactivities; and (ii) in the case of minors, to provide relevant information to USY Summer Programs representatives to keepme informed of my child’s health status.In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to secureand administer treatment, including hospitalization, for the person named above.We acknowledge that the usage of, or involvement with any alcoholic beverages, drugs or narcotics (except thoseprescribed by a physician for medical treatment of applicant), will result in immediate dismissal of the applicant from theprogram, and the applicant will be responsible for all expenses resulting from such involvement and dismissal.Date:Date:Signature of Applicant:Signature of Parent or Guardian (required if applicant is under 21 years of age):Address:Relationship: