Medical Certificate - Camp Ramah

USY HIGHUSY High ▲Division of Ramah Programs in Israel3080 Broadway, New York, NY 10027 ▲ 212-678-8883 ▲ Fax: 212-749-8251 ▲ ramahisrael@jtsa.edu ▲ www.ramah.org.il ▲www.usy.orgMedical CertificateApplicant’s Name:_________________Part I: To be completed by parent or guardian of applicantName: ______________________________ Initial ________________________ Sex: M F Birthdate: _____/____/_____LastFirstAddress: ______________________________________ City:____________________ State: _________ Zip:________________Phone Numbers:____________________________ _______________________________ _______________________________Home Father’s business Mother’s businessA. Emergency Contact (other than parents):Name: ______________________________ ____________________________LastFirstRelationship: ___________________________Address: ___________________________________________________Phone: ________________________________________B. Health Coverage:Name of dentist/orthodontist: ____________________________________________ Phone: ________________________________Health Insurance Company: _____________________________________________ Policy Number: _________________________Address: ____________________________________________________________ Phone: ________________________________C. Authorization:I certify that all information in this medical form is true and accurate and there has been no willful omission ofdata. My child has permission to engage in all prescribed Ramah Programs in Israel activities except as noted.Emergency Authorization: I hereby give permission to the medical personnel selected by the RamahPrograms in Israel Director to order X-rays, routine tests, and treatment for my child, and, in the event that Icannot be reached in an emergency, I hereby give permission to the physician selected by the RamahPrograms in Israel Director to hospitalize, secure proper treatment for, and to order injection and/or anesthesiaand/or surgery for my child as named above. This form may be photocopied for use off of campus.Signature of parent or guardian: _________________________________________________ Date: ___________________________Participant: I also understand and agree to abide with the medical restrictions placed on my activities whilepart of the program in Israel.Signature of participant: _______________________________________________________ Date: ___________________________Medical Certificate Page 1 of 3

USY HIGHUSY High ▲Division of Ramah Programs in Israel3080 Broadway, New York, NY 10027 ▲ 212-678-8883 ▲ Fax: 212-749-8251 ▲ ramahisrael@jtsa.edu ▲ www.ramah.org.il ▲www.usy.orgApplicant’s Name:_________________D. Health History:1. Check all relevant conditions: Frequent ear infections Mononucleosis ALLERGIES Heart defect/disease* Chicken pox Bee stings* Convulsions/epilepsy* Measles Penicillin Diabetes* German Measles Other drugs Bleeding/clotting disorders* Mumps ___________________________ Hypertension Eating disorder* ___________________________ Hay fever/Rose fever Asthma* ___________________________2. Describe any operations or serious injuries (including dates) _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________3. Disability or chronic or returning illness ___________________________________________________________________________________________________________________________________________________________4. Has the applicant been under psychiatric or psychological care within the last two years? Yes No* If yes, include a detailed letter from your doctor describing the situation and treatment. This letter will bekept confidential and under the discretion of the medical personnel.Part II: To be completed in detail by a physician who has examined the applicant within the last three monthsA. Measurements:Height ____________________________________Weight ______________________________________B. Immunization History:Has the participant been protected against (check and note year of most recent immunization):IMMUNIZATION YES NO DATE IMMUNIZATION YES NO DATEDiphtheriaTetanusGerman MeaslesMeaslesMumpsPolio (Salk)Polio (Oral Sabin)Hepatitis AHepatitis BWhooping CoughOther:Other:These immunizations are not required by Israel. Immunizations should be based on consultation with physician.Medical Certificate Page 2 of 3

USY HIGHUSY High ▲Division of Ramah Programs in Israel3080 Broadway, New York, NY 10027 ▲ 212-678-8883 ▲ Fax: 212-749-8251 ▲ ramahisrael@jtsa.edu ▲ www.ramah.org.il ▲www.usy.orgApplicant’s Name:_________________C. Health Examination:The applicant is under the care of a physician and/or therapist for the following conditions: _________________________________________________________________________________________________________________________________________________________________________________________________________________________Current treatment (include current medications): __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Explanation of any reported loss of consciousness, convulsions or concussion: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________D: Recommendations and Restrictions while in Israel:Treatments to be continued in Israel: ___________________________________________________________________________________________________________________________________________________________________Medically prescribed meal plan or dietary restrictions: ______________________________________________________________________________________________________________________________________________________Allergies (food, drugs, plants, insects, etc): ______________________________________________________________________________________________________________________________________________________________Restrictions to full participation: _______________________________________________________________________________________________________________________________________________________________________I have examined the above applicant within THE LAST THREE MONTHS. In my opinion, the above applicant’s condition: Does Does not preclude his/her participation in an active camping program.______________________________________________________________ ________________________________Licensed Physician’s SignatureDate of Examination________________________________________________________________________________________________________________________Address_______________________________________________________Phone Number______________________________________________________________Fax Number___________________________________________________________________________________ _____________Date of Form CompletionBy (Initial if completed by nurse or physician’s assistant)Medical Certificate Page 3 of 3