Test - My Sustainable Summer

Parents, please complete this form in its entirety. We've automatically populated any information you have provided to us previously. OPTIONAL: You will be asked to upload a copy of your primary insurance card and a copy of the student's most recent physical. These are optional and only recommended for a student with pre-existing medical condition that requires special attention from our staff.
Parent Name

First

Last
Parent Email
Student Name

First

Last
Hidden

Program

Primary Medical Insurance Carrier

Examples: Aetna, Blue Cross, etc.
Insurance Policy #
Insurance Carrier Telephone Number
Upload a Copy of Your Medical Insurance Card
Max. file size: 1 MB.

Allowed file formats: jpg, gif, png, pdf. This can be helpful, but as long as we have your policy number, we shouldn't have any problems in the event we need to take your son or daughter to see a medical professional.
Does Your Medical Insurance Company Require Prior Consent?

Family Physician Name

First

Last
Family Physician Address
Street Address City State ZIP Code
Family Physician Phone
Physical Examination (optional)
Max. file size: 1 MB.

OPTIONAL - Upload a copy of the student's most recent physical examination as provided by your doctor. Allowed file formats: jpg, gif, png, pdf.

Please list any prescription medications the student is currently taking and will be bringing to the program.

NOTE: The start or cessation of any behavior modification medication (psychotropics) less than 30 days prior to a program is not permitted without prior approval from our administration. If there is any change in usage of psychotropics we need to know.

Regulation vary by state, but we generally are required to take possession of medications in their original container. Students will come to our health center at designated times where the appropriate dosage will be distributed and then the student self-administers (ie; takes) the medication.
List of prescription medications

Medication Name Dosage and Method/Time of Administration Reason Prescribed/Notes (side effects, etc) Write "NO" if the student cannot self-administer
Please list any non-prescription medications the student will be bringing to the program and is approved to take.
List of non-prescription medications

Medication Name Notes/comments Write "NO" if the student cannot self-administer

Click the plus sign to add multiple medications

I hereby grant Sustainable Summer full authority to take whatever actions it may consider to be warranted under the circumstances regarding my child's health and safety, and I fully release Sustainable Summer from any liability for such circumstances or actions as may be taken in connection therewith. I authorize Sustainable Summer, at its discretion, to place my child, at my own expense and without any further consent, in a hospital for medical services and treatment or, if no hospital is readily available, to place my child in the hands of a licensed medical doctor for treatment.
Signature

Medication Name	Dosage and Method/Time of Administration	Reason Prescribed/Notes (side effects, etc)	Write "NO" if the student cannot self-administer

Medication Name	Notes/comments	Write "NO" if the student cannot self-administer